76881 – Ultrasound, extremity, nonvascular, real-time with image documentation; complete – Average fee amount $120
76882 – Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific – Average fee amount $35
Indications and Limitations of Coverage
Ultrasound of the extremity is a non-invasive imaging technique that uses high-frequency sound waves to evaluate the extremities (arms and legs), providing real-time, two dimensional images. Longitudinal, transverse and oblique images of the area of interest are obtained. Ultrasound, echography and sonography are all terms that may be used interchangeably to describe this particular imaging technique. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.
Extremity ultrasound is indicated for the following conditions:
1. To detect cysts, abscesses, tumors (including evaluation of size of tumors) and effusion;
2. To distinguish solid tumors from fluid-filled cysts;
3. To evaluate tendons (including tears, tendonitis and tenosynovitis), joints, plantar fascia, ligaments, soft tissue masses, ganglion cysts, intermetatarsal neuroma and stress fractures of the metatarsals;
4. To aid in the diagnosis of and surgical removal of foreign bodies.
1. Extremity ultrasound must be performed by qualified and knowledgeable physicians and/or technicians (sonographers) under the general supervision of a physician.
2. Extremity ultrasound 76881 or 76882 is limited to studies of the arms and legs.
3. Extremity ultrasound is not considered medically necessary for the following conditions: plantar warts;
neuromas (where the clinical impression is obvious and ultrasound is not likely to add further information);
superficial abscesses; or
4. Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a “control.”
Neuromas, plantar fasciitis, superficial ganglia, bursae and abscesses unless there is documented evidence of some clinical presentation that obscures the clinician’s ability to establish these simple clinical diagnoses.
In the case of plantar fasciitis, diagnostic ultrasound is NOT to be used in making an initial determination (diagnosis) and then should ONLY be used after a failed course of conservative management. Even at that time, it is to be used only once.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11 – Hospital Inpatient (Including Medicare Part A)
12 – Hospital Inpatient (Medicare Part B only)
13 – Hospital Outpatient
71 – Clinic – Rural Health
73 – Clinic – Freestanding
77 – Clinic – Federally Qualified Health Center (FQHC)
85 – Critical Access Hospital
Extremity ultrasound (Procedure codes 76881 and 76882) is limited to studies of the arms and legs.
Procedure code 76881
A complete ultrasound examination of an extremity (76881) consists of real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality. It is not necessary to image the entire extremity with every diagnostic study.
1. The upper extremity includes any part of the arm from the shoulder joint through the fingers.
2. The lower extremity includes any part of the leg from the hip joint through the toes.
Only the medically necessary areas should be imaged (not required to image shoulder and elbow and wrist, etc.). Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a “control.” Please note, AMDx technicians will continue to perform scans bilaterally of extremities and anatomic structures as required by our interpreting radiologists even though billing and reimbursement may be limited to only the symptomatic extremity.
Procedure Code 76882
A limited examination of an extremity (76882) would be performed primarily for evaluation of muscles, tendons, joints, and/or soft tissues. This is a limited examination of the extremity where a specific anatomic structure such as a tendon or muscle is assessed. (i.e., Trapezius and/or Sacroiliac Joints ?.)
Documentation, coding, billing notes:
1. Maximum number of billable units – extremity: 76881 = 4 (R&L upper extremities, R&L lower extremities.
2. Maximum number of billable units – limited exam: 76882 = 4?, no definitive answer but patient record would have to support necessity of all areas imaged.
3. Patient record must contain documentation of bilateral involvement of joint (76881) or anatomic structures (76882) imaged to be eligible for reimbursement of 2 units of code(s) for bilateral imaging of upper or lower extremities.
4. Codes 76881 and 76882 are NOT eligible for use of modifier “-50” (denoting bilateral services) by UHC.
Ultrasound Extremity Coding Examples:
Bilateral Shoulder with Traps
1 unit – 76881-TCRT
1 unit – 76881-TCLT
1 unit – 76882-TC59RT
1 unit – 76882-TC59LT
Left shoulder, left elbow, left wrist, left trap* (Anatomic modifiers LT or RT are not req’d when only billing 1 unit but can be used)
1 unit – 76881-TC
1 unit – 76882-TC59
Billing and Coding Guidelines
In March 2011, Blue Cross and Blue Shield of Vermont (BCBSVT) and The Vermont Health Plan (TVHP) notified you of upcoming changes to the prior approval list that will
take effect on June 6, 2011. Among the noted changes are the additions of two new 2011 Current Procedural Terminology (Procedure) Codes listed below:
76881 Ultrasound, extremity, nonvascular, real-time with image documentation; complete
76882 Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific
Since making that original decision, we have received additional information on these services. In reviewing the new information, we have made the decision to NOT require prior approval.
NCCI Edit for code 76881
The below codes are not paid separately when submit with 76881 unless untill the modifier used.
36591 36592 76882 76942 76998
• Of note, Procedure ® codes 76881 and 76882 are generally paid if coded and billed correctly by qualified physicians and all other requirements of the Medicare program are satisfied though coverage (the medical record supports the medical necessity of the services). These two codes have 15 minutes intra service time and 11 minutes intra service time respectively unless a separate musculoskeletal diagnostic evaluation is indicated and documented as reasonable and necessary.
Procedure code Diagnostic Ultrasound – Extremity Guidelines
A complete ultrasound examination of an extremity (76881) A complete ultrasound examination of an extremity (76881) consists of real time scans of a specific joint that includes examination of the muscles, ,j , tendons, joint, other soft tissue structures, and any identifiable abnormality.
Code 76882 refers to an examination of an extremity that would be performed primarily for evaluation of muscles, tendons, joints, and/or soft tissues. This is a limited examination of the extremity where a examination of the extremity where a specific anatomic specific anatomic structure such as a tendon or muscle is assessed. In addition, the code would be used to evaluate a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is needed.
76881 …; complete
– Global RVU ( Global RVU (2014): 2 67 2014): 2.67
Professional component (-26): 0.23
Technical component ( Technical component (-TC): 2.44
76882 …; limited, anatomic specific
– Global RVU ( Global RVU (2014): 0 47 2014): 0.47
Professional component (-26): 0.17
Technical comp ( onent (-TC): 0.30
Codes were created to differentiate between a complete and a focused anatomic-specific exam
A complete A complete ultrasound examination of an extremity ultrasound examination of an extremity (76881) is a real time scan of a specific joint to include all
of the following: muscles, tendons, joints, other soft tissues structures, any other abnormality
– Medical record documentation must include a report of the study findings that indicates all of the above structures were examined and the findings for each.
A limited ultrasound examination of an extremity (76882) (76882) is a scan in which a specific anatomic structure (e.g., softtissue mass) is examined tissue mass) is examined
• Soft Tissue/MSK:
– The most common use for soft tissue ultrasound is to distinguish between cellulitis and abscess.
– No specific code exists for soft tissue ultrasound
– The reduced service modifier (-52) is not required for any of the soft tissue codes
– Coding for MSK applications is not well developed. The only existing codes are extremity ultrasound, non-vascular, B-scan and/or real time with image documentation (76882-26), complete infant ultrasound hip, and limited infant ultrasound hip (76886-26).
– Emergency ultrasounds to evaluate for foreign bodies, abscess, tendon laceration as well as other focused area of an extremity would be appropriately coded for with 76882. (76882- codes for a non-vascular extremity limited: includes report on specific anatomic structure such as a soft tissue mass, specific tendon.)
– Ultrasound for miscellaneous musculoskeletal indications including fracture evaluation, tendon rupture, or muscle tear would all be coded by 76882-26.
Additional Musculoskeletal Ultrasound billing tips:
1. Reminder to billers to help prevent inadvertent claim denial of the non-covered diagnosis codes listed at the beginning of this update.
2. An additional tip regarding the use of “sprain/strain” (846 or 847 series) diagnosis codes on ultrasound claims. Healthcare carriers, particularly Blue Cross, will many times request additional info from the patient to determine if the sprain/strain injury occurred in an accident covered by another carrier (auto, work comp, etc.). It can slow the claim payment process
Billing Guidelines for Ultrasounds for Multiple Fetuses
When billing for the ultrasound of multiple fetuses, the following guidelines should be observed.
1. The primary transabdominal code must be billed as one detail with one unit of service. (These codes are 76801, 76805, and 76811.)
2. The add-on code must be billed on one detail line with the units of service equaling the number of additional fetuses (76802, 76810, and 76812).primary code.
4. The add-on codes for “each additional fetus” must be billed with the appropriate multiple gestation ICD-10-CM codes from the table below. (Do not use the fifth-digit subclassifcation digit 0.) The units billed for the add-on ultrasound procedure code is based on the number of “each additional” living fetus(es).
5. One combination of primary and add-on ultrasound codes is allowed per day. Claims denied for additional ultrasounds may be resubmitted as an adjustment with documentation to support the medical necessity of a repeat ultrasound on the same date of service.
6. 76815 is defined to include “one or more fetuses” and can only be reimbursed for one unit of service.
7. When billing 76816 for multiple fetuses, bill 76816 on one detail without a modifier and with one unit for the first fetus. Additional fetuses must be billed on the next detail line using 76816 with modifier 59; the units should equal the number of additional fetuses. This code must also be billed with the appropriate diagnosis code from ICD-10-CM series of diagnosis codes outlined above.
8. In addition to the transabdominal ultrasounds, one unit of 76817 is covered on the same date of service if medically necessary. No modifier is needed. Medical necessity must be documented in the beneficiary’s medical record.
9. Fetal biophysical profiles (76818 and 76819) are covered for additional fetuses. The profile for the first fetus must be billed on one detail, no modifier, and one unit of service. Profiles for additional fetuses must be billed on the next detail, using modifier 59, with the number of units equaling the number of additional fetuses. The appropriate diagnosis code from the 651 series should be billed as outlined above.
10. Claims for fetal biophysical profiles submitted with more than one unit and without the appropriate diagnosis code will be denied. Providers should correct the claim and resubmit as a new claim.
11. Claims for multigestational transabdominal ultrasounds submitted without the appropriate diagnosis will be denied. Providers should correct the claim and resubmit as a new claim.
12. Medical records are required for multiple gestation diagnosis codes from the ICD-10-CM series outlined above that note “fetal loss” or “other” and/or “unspecified multiple gestation.”
13. In cases of fetal demise, the ultrasound procedure that confirms the loss of one, or more, fetuses may be billed with units to include the total number of additional fetuses, dead and living. Subsequent billings should be billed with the units based on the number of “each additional” living fetus.
14. A fetal biophysical profile must not be billed for a fetus that has died.
15. CPT code 76830 must not be billed for a transvaginal ultrasound performed for any pregnancy related condition.
16. Because pregnancies with multiple fetuses are high-risk pregnancies, there is no limit to the number of ultrasounds performed during the pregnancy when billed according to these instructions. However, excessive billing of ultrasounds during a pregnancy is subject to postpayment review for medical necessity, which must be documented in the medical record.