ultrasound

Complete documentation of any radiology procedure is the key to appropriate reimbursement. This is especially true for venous duplex Doppler ultrasound exams, where including fewer than the required number of elements for a complete procedure will result in reimbursement for a limited study.

Medicare’s required changeover to ICD-10 diagnosis coding has shed more light than usual on a topic that requires constant diligence by radiology practices. Regardless of the payer being billed, good procedure coding and diagnosis coding are a must – and the source material for that coding is the documentation found in the radiologist’s report of the imaging examination.

As with any medical procedure, the performance of abdominal ultrasound examinations is defined by specific practice parameters. Likewise, the documentation of those exams must also comply with certain criteria in order for the practice to realize full reimbursement for them. The accepted guideline1 for the performance of abdominal or retroperitoneal ultrasound exams indicates, “Depending on clinical indications, an examination may include the entirety of the abdomen and/or retroperitoneum, a single organ, or several organs.” Similarly, the documentation must contain an exact description of the procedure for proper billing.