Medical Necessity for Multiple Ultrasounds

The CPT code book clearly indicates that multiple ultrasound services that occur during a single encounter can each be reported separately.  However, before payers will reimburse for multiple ultrasound services, the medical necessity of each service must be established.

These four tips will help to effectively support the medical necessity of multiple ultrasound services:

1. Full documentation for each service must be reflected in the ultrasound report(s).  Payers expect that since they are paying for two services, documentation of two services will exist.  Many payers will deny a second service if there is not clear and distinct documentation of two separate services.
2. If two approaches were necessary to visualize all desired organs/views, the report(s) should clearly reflect what was visualized via each approach.
3. Reporting diagnoses to support the need for a second approach is the initial opportunity to support the medical necessity of multiple services.  Examples of possible diagnoses include:
   1. R93.9     Diagnostic imaging inconclusive due to excess body fat of patient
   2. O99.21- Obesity complicating pregnancy, ______ trimester
   3. O34.1-    Maternal care for benign tumor of corpus uteri, ____ trimester (fibroids)
   4. The appropriate diagnosis code for any other maternal anomaly or factor that necessitates a second/alternative view.
4. If a single approach allows the adequate interrogation of all desired factors, then only that one approach should be reported.  For example, if a transvaginal ultrasound (76817) is performed to assess cervical length and the fetal heart rate can be appropriately assessed through the transvaginal approach, then 76815 (Limited Ultrasound) should not be separately reported simply because the fetal heart beat example is found in the 76815 definition.

Inadequate support of the medical necessity of a second ultrasound service during the same encounter may result in a claim denial of one or more of the services.

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