Obstetrical Ultrasounds with Consultation

I am auditing consultation/office visit notes for several maternal fetal medicine specialists. What I receive is the actual radiological report with comments, etc. that include wording such as "30 minutes spent with patient in counseling & coordination of care." The U/S report indicates the referring physician but there is no other evidence that a consultation was requested, no HPI by the MFM other than the Indications for Sonography on the ultrasound report and no other physical exam.

In some cases, the note only says the patient is here for follow-up scan, an ultrasound is done and interpreted but the physician is billing an office visit as well.

Any experts in this area out there?

Codapedia Editor

This sounds pretty minimal.

An E/M service and an ultrasound report should be separate. You should have the consult or o.v. documented on its own. If time is used to select the code, fine, but there should still be some history, the MDM, what was discussed, etc, and then the time statement.

The results of the ultrasound are the images produced by the machine, with measurements. This allows billing of the technical component.

The report of the ultrasound is separate from it: It should be a radiology quality report. Indications, Procedure description, findings. This allows billing of the professional component.

You can't bill both from a single statement. Also, does the 30 minutes include the ultrasound time: I would be careful about that, because it shouldn't.

ACOG has a Procedural Coding book that I found helpful. It's small, but worth the money.

To add...

The requirements for consultation billing are much more onerous than for the office visit. I could see a note " spent 30 min discussing ultrasound results with pt and spouse" as proper coding for an office visit (if there was a little bit of history) but that would never fly for a consultation.