Ultrasound Reimbursement Guide 2015: BioJet Fusion Diagnosis codes explain the rationale for a given service and are a key factor in a payer s evaluation of medical necessity and coverage determination for all healthcare services. The International classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the uniform system for indicating diagnoses or conditions that provide the rationale for services performed. Numerous diagnosis codes may be associated with billing for this procedure. Physicians should select the most accurate diagnosis code(s) to describe the patient s condition. The following table lists some of the relevant diagnosis codes that may be encountered when utilizing BioJet ; note, however, this is not a complete list of potentially applicable codes. Please check the ICD-9-CM coding book for the most accurate code(s) to describe a patient s diagnosis.. Payment Information Diagnosis 600 Hyperplasia of prostate 600.0 Hypertrophy (benign) of prostate 600.1 Nodular prostate 600.10 Nodular prostate without urinary obstruction 600.11 Nodular prostate with urinary obstruction 600.2 Benign localized hyperplasia of prostate 600.9 Hyperplasia of prostate, unspecified 790.93 Elevated prostate specific antigen, (PSA) This is not a complete list of diagnosis codes. Please refer to the ICD-9-CM coding manual for specific guidance.
Office Setting 2015 Average National Medicare Payment 55700 Biopsy, Prostate; needle or punch, single or multiple, any approach $220.96 64450 Injection, anesthetic agent; other peripheral nerve or branch $81.52 76873 $167.69 76942 Ultrasonic guidance for needle placement, imaging supervision and interpretation $60.78 76377 77021 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent work station Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation $64.36 $412.97 There is some controversy on the billing of the nerve block, 64450 injection, anesthetic agent; other peripheral nerve or branch with a transurethral ultrasound (TRUS) and ultrasonically guided the TRUS with biopsy. Check with the commercial carriers for the peripheral block along with the TRUS and biopsy. Reimbursement will be based on contract agreements and coverage issues with each carrier. 77021 (MR guidance) and 76942 (ultrasonic guidance) are simultaneously reimbursable. Your physician is using both MR and ultrasonic (fusion) for needle guidance. *Unlisted CPT codes must be submitted with a strong word description (in block 19) that clearly identifies the services billed. Additionally, a copy of the operative report and BioJet brochure should be attached. Average national allowable as posted by CMS for 2015. For more information visit www.cms.hhs.gov.
Outpatient Setting 2015 Average National Medicare Payment 55700 Biopsy, Prostate; needle or punch, single or multiple, any approach $143.38 64450 Injection, anesthetic agent; other peripheral nerve or branch $46.84 76873 26 $78.30 76942 26 Ultrasonic guidance for needle placement, imaging supervision and interpretation $33.61 76377 26 77021 26 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent work station Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation $40.05 $76.87 76999* 3D prostate biopsy planning * There is some controversy on the billing of the nerve block, 64450 injection, anesthetic agent; other peripheral nerve or branch with a transurethral ultrasound (TRUS) and ultrasonically guided the TRUS with biopsy. Check with the commercial carriers for the peripheral block along with the TRUS and biopsy. Reimbursement will be based on contract agreements and coverage issues with each carrier. 77021 (MR guidance) and 76942 (ultrasonic guidance) are simultaneously reimbursable. Your physician is using both MR and ultrasonic (fusion) for needle guidance. *Unlisted CPT codes must be submitted with a strong word description (in block 19) that clearly identifies the services billed. Additionally, a copy of the operative report and BioJet brochure should be attached. Average national allowable as posted by CMS for 2015. For more information visit www.cms.hhs.gov.
Ambulatory Surgical Center Setting (Facility Billing) 2015 Allowables By City** 55700 Biopsy, Prostate; needle or punch, single or multiple, any approach Atlanta - $775.99 Chicago - $815.53 Los Angeles - $898.38 New York - $920.42 Miami - $736.01 64450 Injection, anesthetic agent; other peripheral nerve or branch Atlanta - $50.55 Chicago - $53.13 Los Angeles - $58.53 New York - $59.96 Miami - $47.95 76873 TC Atlanta - $86.22 Chicago - $90.61 Los Angeles - $99.82 New York - $102.27 Miami - $81.78 There is some controvery on the billing of the nerve block, 64450 injection, anesthetic agent; other peripheral nerve or branch with a transurethral ultrasound (TRUS) and ultrasonically guided the TRUS with biopsy. Check with the commercial carriers for the peripheral block along with the TRUS and biopsy. Reimbursement will be based on contract agreements and coverage issues with each carrier. Average national allowable as posted by CMS for 2015. For more information visit www.cms.hhs.gov. **CMS has not established 2015 national averages for Ambulatory Surgical Centers. The numbers posted here are examples of reimbursements allowable in some large metropolitan areas. It is the physician s responsibility to select and verify the codes that accurately describe the service performed and the corresponding reason for the study. These numbers are subject to change.
Documentation Requirements Permanently recorded images must be maintained in the patient record for all ultrasound examinations, including diagnostic and those when ultrasound is used to guide a procedure. Images can be stored as printed images, on a tape or electronic medium and kept in the patient record or some other archive (they are not required to be submitted with the claim). Documentation of the study must be available to the insurer when requested. A written report of all ultrasound studies should be maintained in the patient s record. For ultrasound guidance procedures, the written report may be filed as a separate item in the patient s record or it may be included within the report of the procedure for which the guidance is used. Payment Policies for Ultrasound Services Medicare Part B will reimburse physicians for medically necessary diagnostic ultrasound services, provided the services are within the scope of the physician s license. Some Medicare Carriers require the physician who performs and/or interprets some types of ultrasound examinations to demonstrate relevant, documented training through recent residency training or post-graduate CME and experience. Please contact your Medicare Part B Carrier for details. Private insurance payment rules about which specialties may perform and receive reimbursement for ultrasound services vary by payer and plan. Some payers will reimburse providers of any specialty for ultrasound services while others may restrict imaging procedures to specific specialties or providers possessing specific certifications or accreditations. Some insurers require physicians to submit applications requesting ultrasound exams and procedures be added to their list of services performed in their practice. It is important to contact your private payers before submitting claims to determine their requirements and request that they add ultrasound to your list of services. Site of Service Selection In an office setting, a physician who owns the equipment and personally performs the ultrasound exam or guidance or performs it through an employed or contracted sonographer, may report the global/non-facility code and report the CPT code without any modifier. If the site of service is the hospital, the 26 modifier, indicating only professional service was provided, must be added by the physician to the CPT code for the ultrasound service. Payers will not reimburse physicians for the technical component in the hospital setting. Regardless of the type of ultrasound equipment that is used, all ultrasound examinations must: 1. Meet the requirements of medical necessity as set forth by the payer 2. Meet the requirements of completeness for the code that is chosen 3. Be documented in the patient s record It is the physician s responsibility to select the codes that accurately describe the service performed and the corresponding reason for the study. Under the Medicare program, the physician should select the diagnosis or ICD-9 code based upon test results, with two exceptions. If the test does not yield a diagnosis or was normal, the physician should use the pre-service signs, symptoms and conditions that prompted the study. If the test is a screening examination ordered in the absence of any signs or symptoms of illness or injury, the physician should select screening as the primary reason for the service. If there are test results, they should be recorded as additional diagnoses.