Guidelines for EXTREMITY Ultrasounds

On March 8th, 2011, posted in: Tips by

CMS is taking a hard look at the significant increase use of code 76881 and 76882. They have also issued specific guidelines for the correct use of each of these codes. Let’s take a look.

The guidelines instruct that complete code 76881 includes real time ultrasound scans of a joint. To be complete, the documentation should reference related “muscles, tendons, joint, and other soft tissue structures, and any identifiable abnormality.”

Example: CPT Changes 2011: An Insider’s View offers the example of a complete exam of the ankle, including the following:

  • Lateral structures (for example, peroneus tendons; fibular ligaments)
  • Medical structures (….posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons; deltoid ligament; neurovascular bundle)
  • Anterior structures(….tibialis anterior tendon; ankle joint)
  • Posterior structures (….Achilles tendon; retrocalcaneal and retroachilles bursa)

In contrast, limited study code 76882 applies to the examination of specific anatomic structure, including muscle, tendon, joint or other soft tissue.
Guidelines for 76882 also explain that the code is appropriate for evaluation of a soft-tissue mass if the physician needs to learn its cystic or solid characteristics.

Example: CPT Changes 2011: An Insider’s View offers the example of the Achilles tendon for an injured patient. This limit exam would code as 76882.
Example: A diabetic patient presents with pain and swelling of the left leg. The physician performs an ultrasound to determine the presence of an abscess. In this case, it is still a limited exam and you would report 76882.

NOTE: This article did not address the use of either code for PRP injection or ultrasound guided injections. At this time each carrier has their own coverage criteria which aren’t necessarily in writing. Most have been allowing reimbursement for guidance, and some others are stating that the procedure is “out of your scope of practice”, if you are not a radiologist.

HOWEVER, the current CCI edits state you should not report 77002 (fluoroscopic guidance for needle placement, e.g. biopsy, aspiration, injection, localization) when you administer trigger point injections (20552-20553) or administers tendon sheath injections (20550-20551). The code does have a ‘1’; which means if you can justify the use of guidance, you can override the bundling with a modifier. Yes I know this is talking about fluoro, and the rest of this article is about ultrasound. With the increase use of ultrasound, it may be just a matter of time until they bundle that into these codes as well.

Remember statements cannot be made about carriers specifically as many coverage guidelines are patient plan specific. Bottom line, I’m not sure I would scan every patient that walks through your door. Use common sense and medical necessity.

Also as a reminder Medicare will not pay for ultrasound guidance of a knee joint unless specific criteria are met; bakers cyst, failed previous injection, and obesity morbid enough that it is impossible to inject the joint space without guidance. If any of this is the case, document, document, document.