This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35049, Non-Vascular Extremity Ultrasound. Please refer to the LCD, for reasonable and necessary requirements.
This article is to assist providers with an understanding of when to bill Current Procedural Terminology (CPT) code 76881 versus CPT code 76882 and the documentation requirements to bill for a complete ultrasound procedure.
The two CPT codes addressed in this article (76881 and 76882) are for diagnostic purposes only and not to be used or billed for therapeutic purposes.
Extremity ultrasound (CPT codes 76881 and 76882) is limited to studies of the arms and legs. The upper extremity includes any part of the arm from the shoulder joint through the fingers including the clavicular and the scapular portions of the upper appendage but excluding the sternoclavicular joint. The lower extremity includes any part of the leg inferior to or below the inguinal ligament.
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Per CPT guidelines, “Code 76881 represents a complete evaluation of a specific joint in an extremity. Code 76881 requires ultrasound examination of all of the following joint elements: joint space (eg, effusion), peri-articular soft-tissue structures that surround the joint (ie, muscles, tendons, or other soft tissue structures), and any identifiable abnormality. In some circumstances, additional evaluations such as dynamic imaging or stress maneuvers may be performed as part of the complete evaluation. Code 76881 also requires permanently recorded images and a written report containing a description of each of the required elements or reason that an element(s) could not be visualized (eg, absent secondary to surgery or trauma).
When fewer than all of the required elements for a ‘complete’ exam (76881) are performed, report the ‘limited’ code (76882).”
According to CPT guidelines, “Code 76882 represents a limited evaluation of a joint or an evaluation of a structure(s) in an extremity other than a joint (eg, soft-tissue mass, fluid collection, or nerve[s]). Limited evaluation of a joint includes assessment of a specific anatomic structure(s) (eg, joint space only [effusion] or tendon, muscle, and/or other soft tissue structure[s] that surround the joint) that does not assess all of the required elements included in 76881. Code 76882 also requires permanently recorded images and a written report containing a description of each of the elements evaluated.”
Documentation must support the right (RT), left (LT), or digit modifiers, as reported.
If less than the required elements for a “complete” exam are reported (e.g., limited number of organs or limited portion of region evaluated), the “limited” code for that anatomic region should be used once per patient exam session.
A “limited” exam of an anatomic region should not be reported for the same exam session as a “complete” exam of that same region.
Professional Component (PC) and Technical Component (TC)
Ultrasound codes are combined, or “global,” service codes that include both the TC and the PC. In the emergency department setting, the hospital will typically report the TC that covers the cost of equipment, supplies, and personnel necessary for performing the service. The PC is reported by the physician for the interpretation of the ultrasound and documentation of the results.
CMS defines hospital-based emergency departments (EDs) as “facilities” and requires radiology CPT codes to be divided into professional and TC.
Use of Modifier-26:
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.
Billing examples:
Example A:
A complete examination of the elbow and shoulder on the right upper extremity would result in CPT code 76881 x 1 being submitted for reimbursement.
Example B:
A limited examination for an Achilles tendon injury would result in CPT code 76882 x 1 being submitted for reimbursement.
Example C:
The following example is of appropriate documentation for a complete non-vascular ultrasound of the ankle. According to the CPT Changes, ALL of the following must be documented to submit CPT code 76881 for reimbursement:
- “Evaluation of the lateral structures of the ankle including:
- The peroneus longus and peroneus brevis tendons for tears, tendinosis, or tenosynovitis. Dynamic imaging is also performed with circumduction of the ankle to assess for peroneal subluxation in real time.
- The anterior talofibular ligament, calcaneofibular ligament, and anterior inferior tibiofibular ligament for tears or scarring. Stress maneuvers are performed to evaluate for ligamentous laxity and anterolateral ankle impingement.
- Evaluation of the medial structures of the ankle including:
- The posterior tibial, flexor digitorum longus, and flexor hallucis longus tendons for tears, tendinosis, or tenosynovitis.
- The deltoid ligament for tears or scarring.
- The neurovascular bundle for signs of nerve swelling or compression.
- Evaluation of the anterior structures of the ankle including:
- The tibialis anterior tendon for tears, tendinosis, or tenosynovitis.
- The ankle joint for effusions, synovitis, arthritic changes, and adjacent ganglion cysts.
- Evaluation of the posterior structures of the ankle including:
- The Achilles tendon for tears, tendinosis, or peritendinitis.
- The retrocalcaneal and retroachilles bursa for fluid collections or inflammation.
- A report is dictated for the patient’s chart”
When billing CPT code 76881, documentation must include this level of detailed information for each joint or for an entire extremity (depending on what was imaged). Failure to document at this level of detail would then only meet the billing requirements for CPT code 76882.
Utilization Parameters
Regardless of the number of joints examined in a single extremity, CPT code 76881 or 76882 can only be billed once per extremity.