CurrentBlue Cross Blue Shield - TexasPolicy CPCP030

Point-of-Care Ultrasound - POCUS Examination Policy

Governs billing, coding, documentation, and reimbursement expectations for point-of-care (portable) ultrasound examinations performed by qualified providers under Blue Cross and Blue Shield of Texas plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPoint-of-Care Ultrasound - POCUS Examination Policy

Policy CodePolicy CPCP030

Change TypeNo material change

Effective DateJan 7, 2025

Next Review DateN/A

Key ActionProviders must record permanent images and include a final written report and submit supporting documentation upon request to be eligible for separate reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8 codescoded examples provided

images + reportdocumentation requirement

2025-01-07effective date

TC/-26/globalmodifier guidance

Coverage criteria for POCUS

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ALL of the following

NOT SEPARATELY REPORTABLE WHEN
- POCUS is performed as part of an E/M evaluation (i.e., not a standalone/dedicated procedure); in this case the ultrasound is considered integral to the E/M and cannot be submitted separately for reimbursement.
REQUIREMENTS FOR SEPARATE REPORTING
- Permanently recorded images of the ultrasound are included in the member's medical record.
- A final written report documenting the indications, results, and clinical impression is completed and included in the medical record.
- The POCUS includes a thorough evaluation of the organ(s) or anatomic region appropriate to the clinical question (i.e., not merely a brief or incomplete scan).
CODING AND MODIFIERS
- Facilities and providers are responsible for submitting the appropriate CPT codes and/or modifiers for services rendered (including TC for technical, -26 for professional when applicable).
- When both technical and professional components are performed together under the same facility arrangement, bill the global procedure (do not append separate -TC or -26).
- If no CPT code exists for a limited ultrasound examination, report the complete ultrasound study with modifier -52.
PLAN DOCUMENTATION AND PAYMENT
- Listing of representative CPT codes or examples does not guarantee payment; reimbursement is subject to the member's applicable plan documents and the clinical documentation submitted by the provider.
- The plan may request supporting documentation; providers must submit documentation upon request to determine eligible reimbursement.

Coding and image/report requirements

Representative CPT codes for POCUS anatomic areasCPT

76506	Head and Neck example
76604	Chest example
76700	Abdomen example
76801	Obstetrical pelvis example
76830	Non-obstetrical pelvic example
76881	Extremity example
76936	Ultrasonic guidance procedure example
76979	Other procedure example (when appropriate)

Additional POCUS-related CPT codes (guidance and other procedures)CPT

76932	Ultrasonic guidance procedure
76937	Ultrasonic guidance procedure (add-on)
76940	Ultrasonic guidance procedure
76941	Ultrasonic guidance procedure
76942	Ultrasonic guidance procedure
76945	Ultrasonic guidance procedure
76946	Ultrasonic guidance procedure
76948	Ultrasonic guidance procedure
76965	Ultrasonic guidance procedure
76975	Other procedure

1–10 of 17

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Image and report requirement — POCUS must include permanently recorded images and a final written report to be separately reportable.

RequirementPOCUS must include permanently recorded images and a final written report to be separately reportable; without these elements it is considered integral to the E/M and not separately reportable.

Image retentionComplete and limited POCUS exams are real time and should include permanently recorded images.

Report requirementA final written report documenting the interpretation must accompany recorded images for separate reimbursement.

Documentation, claim submission, and payment guidance

Documentation Required

Documentation and Claim Submission

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA-approved code sets and to code claims appropriately according to industry-standard coding guidelines (for example: Uniform Billing Editor, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI Policy Manual and CCI edits). Claims are subject to code edit protocols and claim review, which may include review of benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. The plan reserves the right to request supporting documentation; upon request, providers should submit any additional documentation (including images, clinical notes, indication, results, and clinical impression) needed to determine eligibility for reimbursement. Facilities and providers are responsible for maintaining all images and the medical record documentation that supports the point-of-care ultrasound examination.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines.
Maintain and document images, indications, results, and clinical impressions in the member's medical record.
Submit additional documentation promptly upon request to support medical necessity and reimbursement determination.

Denial Risk

Payment Contingent on Plan and Documentation

Listing of CPT or other codes within this policy does not guarantee payment. Payment is contingent on applicable plan documents (for example: Certificates of Benefits, benefit booklets, Summary Plan Descriptions), provider contract terms, member eligibility, coverage limitations, and submission of adequate supporting documentation demonstrating medical necessity. Failure to adhere to coding and billing policies or to provide requested documentation may result in claim denials or reimbursement adjustments. If a point-of-care ultrasound is performed as part of an E/M evaluation and is not a standalone/dedicated procedure, it is considered integral to the exam and should not be billed separately.

Codes listed in this policy are examples and not an exhaustive list and do not guarantee payment.
Payment decisions are governed by the member's plan documents and provider contract when conflicts arise.
Claims may be adjusted or denied if documentation does not support the service billed or if coding/billing policies are not followed.

Key definitions

Point-of-Care Ultrasound (POCUS) — definition and scope

DefinitionPoint-of-care ultrasound (POCUS) is an ultrasound performed by an appropriately trained provider using a portable ultrasound device to diagnose and treat a medical problem in real time.

ScopePOCUS is intended for bedside, portable evaluation and is not intended to replace a formal departmental ultrasound performed in Radiology.

ProviderMay be performed by physicians or other qualified health care professionals trained to use portable ultrasound devices.

Complete vs Limited Ultrasound — distinction between complete and limited exams

Complete ultrasoundEvaluation of all the major structures of an anatomical location; code descriptors indicate 'complete'.

Limited ultrasoundEvaluation of a certain area for a specific condition; used when only a focused assessment is required.

Documentation expectationBoth complete and limited exams should include permanently recorded images and a final written report for separate reporting; otherwise not separately reportable.

When no code existsIf no CPT code exists for a limited exam, report the complete study with modifier -52.

TC, -26, Global — technical and professional components and global billing

Technical component (TC)Identifies the performance of the test; append modifier TC when billing only the technical component.

Professional component (-26)Identifies the interpretation and the documented written report; append modifier -26 when billing only the professional component.

Global procedureWhen both technical and professional components are billed together and rendered/interpreted by the same provider under the same facility arrangement, bill global codes without -TC or -26.