Ultrasound for Blocks: What Anesthesiologists Should Know

Ultrasound in support of post-operative pain blocks is still billable, but are providers doing all that is required? Today's alert provides a reminder of what they must document in order to be paid.

If you had mentioned the word "ultrasound" to teenagers back in the 1960s, I suspect they would have thought you were referring to the psychedelic grooves of Jimi Hendrix or the loud guitars of Jefferson Airplane. Mention the same term to today's anesthesia providers and you are likely to get a clear and rational description of one of their oft-used medical techniques.

There is no doubt as to the clinical ability of anesthesiologists and anesthetists to correctly utilize ultrasound guidance (USG) during the placement of certain blocks, but how many of these providers know what they must do to ensure payment for this service? While they are certainly not clueless like the hypothetical hipsters referenced above, they may not be completely clear on what can be billed and what must be documented. This article will hopefully provide some additional light.

Blocks and More Blocks

As we have previously reported, the Centers for Medicare and Medicaid Services (CMS) indicated in its 2020 Proposed Medicare Physician Fee Schedule (MPFS) that it is considering bundling USG into the acute pain codes beginning in 2021. For now, however, anesthesia providers can obtain separate payment for USG in connection with the placement of a post-operative pain block. That seems straightforward enough. However, what if USG is used more than once in a single operative session?

There are indeed occasions when, due to medical necessity, a provider needs to perform more than one post-operative pain block in the same case (e.g., interscalene block AND femoral block). In such a circumstance—at least as it concerns cases involving Medicare and carriers that follow the Medicare bundling rules—the provider performing the blocks may NOT bill for more than one unit of USG, even where USG was used in the placement of both blocks. The rationale for this rule originates with the National Correct Coding Initiative (NCCI)—the tool that Medicare uses to determine the bundling of secondary CPT codes into primary CPT codes. The NCCI restricts the billing of CPT 76942, ultrasound, to one unit per patient encounter.

A Matter of Interpretation

The code descriptor for USG used in connection with blocks includes the following language: "imaging supervision and interpretation." Whenever you see such terminology, an interpretive report is required. This means that when you perform USG during the placement of a post-operative pain block you will need to document, and place in the patient's medical record, your interpretive findings. Failure to do so means forfeiture of payment since a key component of the code's criteria was not met.

The 2019 edition of the CPT coding manual contains new language in the Radiology Guidelines section that underscores the elements that must be present in the imaging report. Specifically, the report must provide "written documentation of interpretive findings of information contained in the images and radiologic supervision of the service." Based on this verbiage, we recommend that you create a USG report template to be used whenever this service is performed. Furthermore, we require that you provide us with your interpretive findings, i.e., report, which must at a minimum convey at least one of the following ideas:

• Ultrasound guidance used to guide the needle for satisfactory placement (e.g., "Under US, needle guided and appropriately placed," "Ultrasound guidance used for needle placement").
• Ultrasound guidance used to view medication diffusion (e.g., "US used to visualize spread of anesthetic," "Medication spread viewed under U/S").

Typically, groups will embed one of these USG report elements as a preformulated attestation statement on the anesthesia record or block sheet that we receive. If you are using a pre-formulated attestation, it must come with a check box and be checked in order for the USG to be submitted for payment. Alternatively, the attestation can be circled. If there is no embedded report attestation to check or circle, you will need to separately document your USG findings based on the above examples.

Image is Everything

In addition to the report requirement, we want to remind you that you cannot get paid for your USG service if you do not retain the image. This can be done by hard copy or digitally, but it must be present and available. The Radiology Guidelines section of CPT 2019 clearly indicates that all supervision and interpretation imaging codes require "image documentation in the patient's permanent record."

I recall visiting with doctors at a certain anesthesia group years ago who insisted that they were retaining the USG images digitally, only to find out later that the digital images were not being associated with the patients in question. In other words, the images were present but simply not tied to any particular patient! This should serve as a reminder to all groups that they should confirm that their USG images are (a) being retained, AND (b) able to be connected back to the patients for whom the services were performed. It does no good to retain images if they cannot be connected to the patient in the event of an audit.

Silence is Not Golden

Our coders are careful to adhere to all CPT and payer billing rules. They code based on what you document. If you provide the above-referenced report language on the anesthesia record or block sheet, and we have an indication that you retained the ultrasound image, our coders will submit the USG service on the claim. Therefore, we are requesting that you inform us if it is NOT your practice to retain in the patient's record (or equivalent digital database) an image of the ultrasound guidance that can be retrieved and associated with the patient. We will maintain your communication to us in this regard and will code accordingly until such time as you indicate a change in practice. Many of you have already provided this information to us. This is simply a reminder to all our valued clients, including our newest members, that it is up to you to inform us if the above conditions for billing USG are, or are not, being met. As always, we value your cooperation in the compliance process.

If you have questions about this topic, or wish to provide information to us about USG image retention in your practice, please do not hesitate to contact your account representative. We will address USG for invasive lines in a future alert.