Bedside or point-of-care ultrasound, sometimes abbreviated BUS or POCUS, is increasingly used in diagnostic and procedural services. To properly report these ultrasound services, it is important to understand when services are reported, required documentation, and appropriate codes for studies of specific organs and/or anatomic sites.
Current Procedural Terminology (CPT®) instructs that ultrasound services are separately reportable in addition to an evaluation and management (E/M) service when the service includes all of the following:
Use of ultrasound without each of these elements is not separately reported (exceptions do apply for certain ophthalmic ultrasounds). The American College of Radiology has adopted standards for documentation of test results that include the following:
Inclusion of these elements in documentation of ultrasound studies provides support for selection of the appropriate ultrasound procedure code and separate reporting of the service when provided in conjunction with an E/M or other service.
CPT includes codes for...