Documentation of E/M with Ultrasound
Coding Tip: Documentation of E/M with Ultrasound
The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; David Smith, MBA, CPC
Introduction
When a physician/Qualified Health Care Professional performs a significant, separately identifiable evaluation and management (E/M) service on the same date as a billed OB ultrasound, the E/M may be reported with modifier -25—and a separate consult note is not required. What is required is documentation in the medical record that supports that the E/M work was distinct from the ultrasound service.
Why this matters
Some practices are telling providers they must create a standalone consult note “separate from the ultrasound report” to bill an E/M. That’s not the standard. Modifier -25 signals that supporting documentation exists in the chart; it does not mandate a separate note format.
Practical guidance for documentation (what payers actually need)
1) The ultrasound report should stand on its own
Document the required ultrasound elements as usual (indication, technique, findings/measurements, impression).
2) The E/M work should be clearly identifiable (even if in the same note)
You can document the E/M in the same encounter note as long as it’s clearly separated (headings help), and includes work beyond what’s inherent to performing/interpreting the ultrasound.
Good structure (example headings):
· Ultrasound Report (separately complete)
· E/M Assessment & Plan
3) Use modifier -25 on the E/M when criteria are met
Modifier -25 is used to indicate the E/M is “significant” and “separately identifiable” from the ultrasound/procedure performed that day.
When billing E/M is appropriate with an OB ultrasound (common MFM scenarios)
Bill an E/M when the visit includes additional, medically necessary evaluation/management, such as:
· New/changed diagnosis or complication addressed (e.g., new FGR, new ventriculomegaly, new abnormal Dopplers)
· Substantive counseling and management planning that goes beyond explaining the study or “reviewing normal results”
· Medication adjustments, coordination of care, orders, referrals, and follow-up planning when responsibility for executing these tasks lies with the MFM. This excludes time (or medical decision-making) related to ordering tests with billable CPT codes (e.g., recommending or performing a follow-up ultrasound)
· Independent review of records and synthesis/management beyond the imaging result
SMFM has explicitly described using E/M + ultrasound with -25 when the E/M work is more substantive than routine procedure-related discussion.
When an E/M should NOT be billed (avoid denials)
Do not bill a separate E/M if the only work performed was:
· Explaining risks/benefits of the ultrasound or what will happen during the exam
· Delivering normal results with no additional management
· Counseling that is essentially inherent to performing/interpreting the ultrasound that day
Sample documentation language
Option A: Same note, clearly separated
E/M Assessment & Plan (distinct from ultrasound interpretation): Reviewed outside prenatal records and prior imaging. Discussed new finding of ___ and differential. Counseled on maternal/fetal risks, recommended ___, ordered ___, coordinated referral to ___, and established follow-up interval ___. Total physician time today: ___ minutes (exclusive of ultrasound interpretation/reporting).
Option B: Separate note optional (not required)
This E/M service was medically necessary and separately identifiable from the ultrasound performed today; modifier -25 appended.
(If you use time-based coding, keep time exclusive of ultrasound interpretation/report work.)
A separate consult note is not required; what’s required is documentation in the record supporting a significant, separately identifiable E/M service beyond the ultrasound—reported with modifier -25 when appropriate.
Sources
· American Medical Association. CPT® Professional Edition. Modifier -25 definition and reporting guidance.
· Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services.
· CMS. 2021–Present Office/Outpatient E/M Documentation Guidelines.
· AMA. Reporting CPT Modifier -25 (guidance document).
Members should submit any coding questions to the SMFM Coding Committee “Ask a Coding Question” website (https://www.smfm.org/ask-a-coding-or-PM-question). Additional information and resources are also available on our coding website (smfm.org/coding).