Diagnostic Musculoskeletal Ultrasound

PM&R News   •   April 2022

Ultrasound for the diagnosis of musculoskeletal pathology is becoming increasingly widespread. However, many clinics still do not have a standardized method for documenting diagnostic ultrasound procedures. We have generated several basic diagnostic ultrasound templates for use by Physiatrist to assist with appropriate documentation that can communicate findings, and help providers capture charges for work performed in the assessment of the patient.  Please see these templates as listed below: 

Limited Diagnostic Ultrasound of the ***, Performed by Dr. *** during their clinic visit on **/**/**** 

A 2D, gray scale B mode ultrasound limited ultrasound of the *** for evaluation of [SELECT:  muscles, bones, joints, tendons, related soft tissue structures] (using a *** ultrasound machine with *** probe).  Pertinent findings include ***

ASSESSMENT: ***

Limited Diagnostic Ultrasound of the *** Nerve, Performed by Dr. *** during their clinic visit on **/**/**** 

A 2D, gray scale B mode ultrasound limited ultrasound of the *** Nerve for evaluation of *** (using a *** ultrasound machine with *** probe).  The normal fascicular pattern with hypoechoic longitudinal neuronal fascicles interspersed with hyperechoic interfascicular epineurium were observed. The normal course of the nerve was visualized, and pertinent findings include ***. 

ASSESSMENT: ***

Complete Diagnostic Ultrasound of the *** Shoulder, Performed by Dr. *** during their clinic visit on **/**/**** 

A 2D, gray scale B mode complete ultrasound of the *** shoulder (using a *** ultrasound machine with linear probe) with evaluation of the muscles, bones, joints, tendons and related soft tissue structures. Images of the biceps tendon, subscapularis, supraspinatus, infraspinatus, Glenohumeral joint, and Acromioclavicular Joint were obtained.  The typical pennate and “starry night” pattern is observed in visualized muscle.  The hyperechoic bone contours exhibit continuity.  The typical anechoic joint space is observed without fat pad displacement.  Hyperechoic tendon is observed without discontinuity of the fibrillar pattern.  No other changes we visualized to the related soft tissue structures.

ASSESSMENT:  normal *** shoulder ultrasound

Complete Diagnostic Ultrasound of the *** Knee, Performed by Dr. *** during their clinic visit on **/**/**** 

A 2D, gray scale B mode complete ultrasound of the right knee (using a GE Logiq-e ultrasound machine with linear probe) with evaluation of the muscles, bones, joints, tendons and related soft tissue structures. Images of the suprapatellar region, patellar tendon region, medial joint space, lateral joint space and posterior knee were obtained.  The typical pennate and “starry night” pattern is observed in visualized muscle.  The hyperechoic bone contours exhibit continuity.  The typical anechoic joint space is observed without fat pad displacement.  Hyperechoic tendon is observed without discontinuity of the fibrillar pattern.  No other changes to the related soft tissue structures.

ASSESSMENT:  normal *** knee ultrasound

Furthermore, we have developed the following documentation for assisting providers in appropriately capturing appropriate CPT codes for ultrasound procedures preformed in the care of the patient. 

Diagnostic Ultrasound CPT Coding: 

  • 76881: Represents a complete evaluation of a specific joint in an extremity. 
    • Requires ultrasound examination of all of the following joint elements: joint space, peri-articular soft tissue structures that surround the joint, and any identifiable abnormality.
    • It also requires permanently recorded images and a written report containing a description of each of the required elements or reason why an element could not be visualized.
  • 76882: Represents a limited evaluation of a joint or an evaluation of a structure in an extremity other that a joint (soft tissue mass, fluid collection, or nerve). 
    • Limited evaluation of a joint includes assessment of a specific anatomic structure that does not assess all of the required elements in 76881. 
    • This also requires permanently recorded images and a written report containing a description of each of the elements evaluated.
  • 76942: Ultrasonic guidance for needle placement (biopsy, aspiration, injection, localization device)
    • If you start out just looking and then insert a needle 76942 is correct.
  • 76970: is the code for Ultrasound study follow up.

Procedural Ultrasound Coding: 

  • These codes all fall under the 206 parent code
  • 20600 (main code) Arthrocentesis, aspiration and/or injection, small joint or bursa (fingers, toes) without ultrasound guidance.
    • 20604 is 20600 with ultrasound guidance, and permanent recording.
  • 20605(main code) Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (temporomandibular, acromioclavicular, wrist, elbow, ankle, olecranon bursa) without ultrasound guidance.
    • 20606 is 20605 with ultrasound guidance, with permanent recording.
  • 20610- Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (shoulder, hip, knee, subacromial bursa) without ultrasound guidance.
    • 20611 is 20610 with ultrasound guidance, with permanent recording.

Billing and Coding Pearls

  • If you are just looking 76881 or 76882 are correct. 
  • If you start out just looking and the insert a needle 76942 is correct. 
  • If the intent at the beginning of the procedure is to insert a needle then any of the 206 parent codes are appropriate. 
  • You cannot use 76942 and any of the 206 parent codes together.

We hope that you will find this information educational in assisting you in practice to document and capture ultrasound procedures.

Guest Writer: Zakari R. Dymock MD, MS