Question:
What are the documentation requirements when performing a microbubble ultrasound 76978/76979 and a diagnostic ultrasound 76705 during a liver biopsy? What verbiage is required to support performing/charging both in the report?
Answer:
There must be separate orders and medical necessity for both, and there should be separate technical exams. It is more common that a non-contrast diagnostic ultrasound is done at an earlier session/day, and then based on the findings from that exam the contrast exam would be ordered. Documentation would need to indicate that two separate exams were done, with findings from each. The reports should be separate, at a minimum separate paragraphs. Keep in mind that Medicare has a CCI edit, and while it may be over-ridden with a modifier, you will have to justify that. For Medicare, the fact that there are two separate exams is not enough justification. The exams would have to be done at separate sessions, or on separate body areas.
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