Coding

A Guide to Ultrasound of the Shoulder, Part 1: Coding and Reimbursement

Am J Orthop. 2016 March;45(3):176-182

References

1. Sivan M, Brown J, Brennan S, Bhakta B. A one-stop approach to the management of soft tissue and degenerative musculoskeletal conditions using clinic-based ultrasonography. Musculoskeletal Care. 2011;9(2):63-68.

2. Sharpe R, Nazarian L, Parker L, Rao V, Levin D. Dramatically increased musculoskeletal ultrasound utilization from 2000 to 2009, especially by podiatrists in private offices. Department of Radiology Faculty Papers. Paper 16. http://jdc.jefferson.edu/radiologyfp/16. Accessed January 7, 2016.

3. Blankstein A. Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope. World J Orthop. 2011;2(2):13-24.

4. Sinha TP, Bhoi S, Kumar S, et al. Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients. J Emerg Trauma Shock. 2011;4(4);443-445.

5. Bica D, Armen J, Kulas AS, Young K, Womack Z. Reliability and precision of stress sonography of the ulnar collateral ligament. J Ultrasound Med. 2015;34(3):371-376.

6. Tomer K, Kleinbaum Y, Heyman Z, Dudkiewicz I, Blankstein A. Ultrasound diagnosis of fractures in adults. Akt Traumatol. 2006;36(4):171-174.

7. Middleton W, Payne WT, Teefey SA, Hidebolt CF, Rubin DA, Yamaguchi K. Sonography and MRI of the shoulder: comparison of patient satisfaction. AJR Am J Roentgenol. 2004;183(5):1449-1452.

8. Teefey SA, Rubin DA, Middleton WD, Hildebolt CF, Leibold RA, Yamaguchi K. Detection and quantification of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance and arthroscopic finding in seventy-one consecutive cases. J Bone Joint Surg Am. 2004;86-A(4):708-716.

9. Roy-JS, Braën C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterization of rotator cuff disorders: a meta-analysis. Br J Sports Med. 2015;49(20):1316-1328.

10. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal Imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182-188.

11. Eustace J, Brophy D, Gibney R, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis. 1997;56(1):59-63.

12. Partington P, Broome G. Diagnostic injection around the shoulder: Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg. 1998;7(2):147-150.

13. Rutten M, Maresch B, Jager G, de Waal Malefijt M. Injection of the subacromial-subdeltoid bursa: Blind or ultrasound-guided? Acta Orthop. 2007;78(2):254-257.

14. Kang M, Rizio L, Prybicien M, Middlemas D, Blacksin M. The accuracy of subacromial corticosteroid injections: A comparison of multiple methods. J Shoulder Elbow Surg. 2008;17(1 Suppl):61S-66S.

15. Yamakado K. The targeting accuracy of subacromial injection to the shoulder: An arthrographic evaluation. Arthroscopy. 2002;19(8):887-891.

16. Henkus HE, Cobben M, Coerkamp E, Nelissen R, van Arkel E. The accuracy of subacromial injections: A prospective randomized magnetic resonance imaging study. Arthroscopy. 2006;22(3):277-282.

17. Sethi PM, El Attrache N. Accuracy of intra-articular injection of the glenohumeral joint: a cadaveric study. Orthopedics. 2006;29(2):149-152.

18. Naredo E, Cabero F, Beneyto P, et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol. 2004;31(2):308-314.

19. Finnoff JT, Hall MM, Adams E, et al. American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine. Br J Sports Med. 2015;49(3):145-150.

20. Sibbitt WL Jr, Peisajovich A, Michael AA, et al. Does sonographic needle guidance affect the clinical outcome of intra-articular injections? J Rheumatol. 2009;36(9):1892-1902.

For rotator cuff tears, ultrasound is also comparable diagnostically with MRI (Figures 2A, 2B). In a prospective study of 124 patients, MRI and ultrasound had comparable accuracy for identifying and measuring the size of full-thickness and partial-thickness rotator cuff tears, with arthroscopic findings used as the standard.⁸ A 2015 meta-analysis published in the British Journal of Sports Medicine showed that the diagnostic accuracy of ultrasound, MRI, and MR arthrography in the characterization of full thickness rotator cuff tears had >90% sensitivity and specificity. As for partial rotator cuff tears and tendinopathy, overall estimates of specificity were also high (>90%), while sensitivity was as high as 83%. Diagnostic accuracy of ultrasound was similar whether it was performed by a trained radiologist, sonographer, or orthopedist.⁹

Medicare reimbursements for MSK ultrasound studies has increased by 316% in the past decade.² Private practice MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009.² In 2010, non-radiologists accounted for more ultrasound-guided procedures than radiologists for the first time.¹⁰ MSK ultrasound is still underutilized compared to MRI. This underutilization is also unfortunate economically. The cost of MRIs is significantly higher. According to Parker and colleagues¹⁰, the projected Medicare cost for MSK imaging in 2020 is $3.6 billion, with MRI accounting for $2 billion. They also concluded that replacing MSK MRI with MSK ultrasound when clinically indicated could save over $6.9 billion between 2006 and 2020.¹¹

Ultrasound-Guided Procedures

MSK ultrasound has gained significant ground on other imaging modalities when it comes to procedures, both in office and in the operating room. The ability to have a small, mobile, inexpensive machine that can be used in real time has dramatically changed how interventions are done. Most imaging modalities used to perform injections or percutaneous surgery use fluoroscopy machines. This exposes the patients to significant radiation, costs significantly more, and usually requires a secondary consultation with radiologists in a different facility. This wastes time and money, and results in potentially unnecessary exposure to radiation.

Accuracy is the most common reason for referral for guided injections. The guidance can help avoid nerves, vessels, and other sensitive tissues. However, accuracy is also important to make sure the injection is placed in the correct location. When injections are placed into a muscle, tendon, or ligament, it causes significant pain; however, injections placed into a bursal space or joint do not cause pain. Numerous studies have shown that even in the hands of experts, “simple” injections can still miss their mark over 30% of the time.^12-19 Therefore, if a patient experiences pain during a bursal space or joint injection, the injection was not placed properly.

The American Medical Society for Sports Medicine Position Paper on MSK ultrasound is based on a systematic review of the literature, including 124 studies. It states that ultrasound-guided joint injections (USGI) are more accurate and efficacious than landmark guided injections (LMGI), with a strength of recommendation taxonomy (SORT) evidence rating of A and B, respectively.¹⁹ In terms of patient satisfaction, in a randomized controlled trial of 148 patients undergoing knee injections, Sibbitt and colleagues²⁰ showed that USGI had a 48% reduction (P < .001) in procedural pain, a 58.5% reduction (P < .001) in absolute pain scores at the 2-week outcome mark, and a 75% reduction (P < .001) in significant pain and 62% reduction in nonresponder rate.²⁰ From a financial point of view, Sibbitt and colleagues²⁰ also demonstrated a 13% reduction in cost per patient per year, and a 58% reduction in cost per responder per year for a hospital outpatient center (P < .001).

Coding

Coding for diagnostic MSK ultrasound requires an understanding of a few current procedural terminology (CPT) codes (Table 2). Ultrasound usage should follow the usual requirements of medical necessity and the CPT code selected should be based on the elements of the study performed. A complete examination, described by CPT code 76881, includes the examination and documentation of the muscles, tendons, joint, and other soft tissue structures and any identifiable abnormality of the joint being evaluated. If anything less is done, then the CPT code 76882 should be used.

New CPT codes for joint injections became effective January 2015 (Table 3). The new changes affect only the joint injection series (20600-20610). Previously, injections could be billed with CPT code 76942, which was “Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.” This code can still be used, but with only specific injections, when the verbiage “with ultrasound/image guidance” is not included in the injection CPT code descriptor (Table 4).