Adequate documentation is an essential component to patient care, but it is also required for billing. There should be a permanent record of the ultrasound examination and its interpretation. Comparison with previous relevant imaging studies is helpful and always performed when available. Images of all appropriate areas, both normal and abnormal, should be recorded in appropriate storage format. Variations from normal size or dimension should be accompanied by measurements. Images should be labeled with the examination date, patient identification, and image orientation. A report of the ultrasound findings should be included in the patient’s medical record, regardless of where and when the study is performed.

For coding, first of all, documentation is essential. In addition to ultrasound findings, appropriate indications for examinations should be documented. For the process of billing, the correct coding with appropriate modifiers must be used. The coding may change, and, therefore, the surgeon should update the coding using the current “CPT” and “ICD.” Like all procedures in today’s environment, surgeons or their billers must follow up on reimbursement for ultrasound. If appropriate reimbursement is not received, the surgeon should discuss the issue with the insurer and, when necessary, with local or national professional societies.

For all ultrasound examinations, there are professional and technical components. Surgeons performing office ultrasound (e.g., transabdominal ultrasound) by themselves using their own equipment can code for both the professional and the technical components. In such a case, no modifier is required. For surgeons performing ultrasound in a facility or hospital (e.g., ultrasound in the emergency room, intensive care unit, or operating room), the situation is more complex. If a surgeon performs ultrasound examinations (with or without a technician) using the hospital’s machine, he or she should use modifier -26 to charge only for the professional component. In a facility or hospital, a surgeon performing ultrasound by himself or herself (without the help of a hospital technician) using his or her own machine can charge only for the professional component for Medicare patients. In this case, the surgeon must add modifier -26 (they must include this; otherwise, the claim will be rejected) because Medicare pays only for the professional component on the HCFA 1500. For other insurers (such as Blue Cross/Blue Shield), both components may be paid; however, the surgeon should first discuss this issue with a medical director of the insurance company. Otherwise, the modifier -26 should be used for the professional charge only.

Table 22.2 is a list of coding for ultrasound examinations commonly performed in a surgical practice of the abdomen, including office-based ultrasound and hospital-based ultrasound.