Point-of-Care Ultrasound Documentation: Understanding the Basics

When it comes to emergency medicine, every second counts. Waiting around for access to a traditional, console ultrasound machine—and a radiologist to interpret the results—may not always be possible. That’s where point-of-care ultrasound, or POCUS, comes into play. By using small portable ultrasound machines, emergency department physicians can interpret results in a matter of minutes. This has become a game-changer for medical systems across the globe.

However, one thing that’s often overlooked in hospitals and emergency departments is the documentation of POCUS scans. In fact, a 2020 study published in the BMJ Open Quality journal entitled “Improving the documentation quality of point-of-care ultrasound scans in the emergency department” found that POCUS documentation was as low as 38% for some examinations. This simply isn’t sustainable for a number of reasons, including billing and reimbursements as well as liability.

Yet we know that the majority of documentation systems and workflows are complex or disjointed and take too much time to complete, so it’s no surprise that documentation suffers. There’s just not enough time in the day—especially when performing POCUS in trauma situations that are life threatening. That’s why we created Exo Works™, our POCUS workflow solution that allows providers to document, submit for billing, and send ultrasound exams to PACS seamlessly.

But before we talk more about Exo Works and how it can improve your POCUS program’s documentation, let’s take a deeper dive into POCUS and documentation, including:

• How does point of care ultrasound work?
• Can you bill for point of care ultrasounds?
• What are the point of care ultrasound guidelines for documentation and billing?
• How can you use a POCUS workflow solution to improve your documentation processes?

What Is a POCUS Exam?

A point-of-care ultrasound exam is simply an ultrasound exam performed at the “point of care,” such as at the bedside in emergency departments. There are two primary types of machines that fall under the point-of-care ultrasound definition: handheld devices and cart-based systems. These ultrasounds are more portable than the traditional console systems, where patients must be transported to the ultrasound machine.

There are a number point-of-care ultrasound machine benefits, including:

• They are more widely accessible. Because they are cart-based or handheld devices, POCUS scans can be performed nearly anywhere.
• They offer real-time imaging. With POCUS, scans can be viewed in real-time, which can quicken time to diagnosis. And, with point-of-care ultrasound training, providers can interpret these scans quickly and accurately.
• They are cost-effective. Traditional console ultrasound machines can cost anywhere from $40,000 to $200,000 or more, but POCUS devices are often $10,00 or less in cost.

What Can Point-of-Care Ultrasound Be Used For?

Point-of-care ultrasounds can diagnose and detect a variety of different medical issues. For example, an article published by the American Association of Family Practitioners (AAFP) reports that there is clinically compelling evidence that POCUS can be used to identify:

• Abdominal aortic aneurysm
• Appendicitis
• Biliary colic and cholecystitis
• Bowel obstruction and perforation
• Decreased cardiac ejection fraction and presence of pericardial effusion
• Deep venous thrombosis
• Elevated intracranial pressure
• Hydronephrosis
• Intraperitoneal bleeding in trauma
• Obstetric and gynecologic conditions (such as ectopic pregnancy)
• Respiratory distress
• Retinal detachment
• Skin and soft tissue infections

Of course, there are still many instances that necessitate the use of traditional radiology practices. POCUS programs are not replacing radiology departments. Instead, a point-of-care ultrasound machine is designed to be used in emergency departments and other similar settings where a bedside ultrasound will suffice. This quickens time to diagnosis, limits patient exposure to radiation, and frees up radiology departments to focus on taking and interpreting images that require traditional and more detailed scans.

What Are POCUS Protocols Around Documentation?

POCUS documentation includes all of the necessary information about a POCUS scan that a provider or hospital needs to properly record to archive results and bill for the service. Like nearly all medical procedures, it’s essential for POCUS imaging exams to be documented. The need is two-fold.

• It limits provider and hospital liability should something go wrong following a decision made from an ultrasound image. If a patient dies during a surgery that was found to be medically necessary, for example, having that imaging proves that the provider performed the correct course of action.
• It allows for billing and reimbursement. Ultrasound billing guidelines, which we’ll discuss next, require that various pieces of information be recorded. Hospitals and providers that don’t document appropriately are missing out on being reimbursed for POCUS usage.

What Should POCUS Documentation Include?

In general, POCUS documentation should include three key pieces: the medical necessity for a scan, the interpretation, and the retention of images. To provide additional context, there are a few major bodies that have laid out guidelines on what exactly should be included in the documentation of a POCUS scan. Fortunately, most guidelines are quite similar, so creating POCUS documentation workflows that include all guidelines is fairly straightforward.

The Centers for Medicare & Medicaid Services (CMS) guidelines for billing ultrasounds use the standards laid out by the American College of Radiology (ACR) as their template. As of 2010, the ACR recommends that the following pieces of information be documented:

1. Demographic information, which includes facility and location, patient name, health care provider, type of exam, date and time of exam, and more.
2. Relevant clinical information to the exam.
3. Body of report, which includes procedures and materials, findings, potential limitations, clinical issues, and comparison studies and reports.
4. Impression, which includes specific diagnosis (when possible), differential diagnosis, full-up diagnostic studies, and significant patient reactions.

Along with these four components, providers should also archive images. The ACR recommends that POCUS programs implement standard computer-generated templates to both ensure that all information is properly captured and remove barriers to completion.

The American College of Emergency Physicians (ACEP) also published their own guidelines in 2018, which are quite similar to those laid out by the ACR. Along with image capture, their documentation recommendations include six key components:

1. Patient demographics, which includes name, exam type, provider information, and more.
2. An indication for the exam, which includes the reason for performing the scan.
3. Views, which shares if the views were adequate, limited, or not obtained.
4. Findings, which details what was absent, present, or indeterminate.
5. Interpretation, which provides a clinical interpretation of the findings.
6. Quality assurance, which sets in place a QA process for ensuring that provider scans and interpretations are regularly reviewed for accuracy.

In addition to these guidelines, it’s also recommended that providers document who performed the procedure, who interpreted the scans, and the scope of the exam.

Can POCUS Be Billed?

Yes, POCUS imaging exams can be billed, assuming all of the proper documentation guidelines, such as report documenting and image storage, have been followed. It is vital to document medical necessity and findings as accurately as possible.

What Are the CPT Codes for Ultrasound?

There are a variety of different Current Procedural Terminology (CPT) codes that may be used for the billing of POCUS imaging exams in the emergency room. POCUS bedside ultrasound CPT codes that are most commonly used include:

• 20611 CPT Code: For ultrasound required for arthrocentesis, aspiration and/or injection
• 49083 CPT Code: For imaging required for abdominal paracentesis
• 76512 CPT Code: For ophthalmic ultrasound
• 76604 CPT Code: For reimbursement of chest ultrasound
• 76705 CPT Code: For abdominal ultrasound
• 76775 CPT Code: For retroperitoneal ultrasound
• 76815 CPT Code: For ultrasound of pregnant uterus
• 76817 CPT Code: For transvaginal ultrasound of pregnant uterus
• 76937 CPT Code: For ultrasound required for vascular access
• 76942 CPT Code: For ultrasound required for needle placement
• 93308 CPT Code: For echocardiography or transthoracic ultrasound
• 93971 CPT Code: For scan of extremity veins

For full details and requirements of each individual CPT code, as well as the common modifiers that are associated with each, there are several resources available. The American College of Emergency Physicians’ (ACEP) Ultrasound FAQ is an excellent place to get started.

How Can You Improve Point-of-Care Ultrasound Documentation?

There are a number of ways to improve POCUS documentation, and they all center around ensuring that workflows are standardized and easy to use. One 2020 study in the Pediatric Quality and Safety journal, “Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department,” enacted three interventions to attempt to improve both POCUS documentation completion and the correct selection of CPT codes. The interventions included:

1. Creating a standard for image documentation.
2. Building documentation and billing templates within the electronic medical record (EMR).
3. Providing physician education and feedback on best practices for using the system.

After implementing each of these, they found that the “complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions.” And while this study focuses on the use of pediatric point of care ultrasound in the emergency department, the results are certainly telling. The quicker and easier it is to complete documentation, the more likely providers are to do it. And as the article found, increased documentation completion can lead to additional opportunities for billing and lower overall lost revenue—not to mention the decrease in liability from storing completed documentation and images.

So how do you implement these sorts of changes in your POCUS program? Perhaps the easiest way is to find an all-in-one workflow solution that does the work for you. Exo Works, our POCUS workflow solution, creates a simplified way for clinicians to document, review and bill for POCUS:

• Perform a scan with any DICOM-enabled ultrasound machine.
• Review and document findings in seconds from a phone or laptop, using standardized templates.
• Automatically save to EMR and PACS for billing and storage whenever the internet is available.
• Securely distribute and access ultrasound exams through the cloud for archival and easy access.

With Exo Works, ensure that provider scans are accurate and that users can fully complete their documentation.

Exo Works: POCUS Workflow Made Easy

At Exo, we’re dedicated to easing the burden that physicians and hospital systems face on a daily basis by providing an all-in-one ultrasound workflow ecosystem that’s built for the future of medicine. Our workflow solution helps organizations and providers to realize benefits like:

• Maximizing time spent with patients
• Increasing POCUS billing rates
• Decreasing overall liability through documentation

With Exo Works, you can accommodate order- and encounter-based ultrasound workflows from one easy-to-use solution that allows for documenting, reporting, billing, and archiving. Ready to learn more? Schedule a demo to learn how Exo Works can empower your POCUS program.