Practical Aspects of Point-of-Care Ultrasound: From Billing and Coding to Documentation and Image Archiving

As point-of-care ultrasound (POCUS) is increasingly implemented into the routine clinical practice of nephrologists, it is important to consider the practical aspects of a POCUS workflow including documentation, image archiving, billing, and coding. Documentation of POCUS studies performed allows for accurate information exchange among all members of the care team and can be effectively implemented using preset documentation worksheets. Image archiving systems provide a mechanism for review, storage, and quality assurance processes that are directly linked to the patient's record. Understanding the coding components required for billing and developing efficient systems to support billing and coding can contribute to ensuring financial support for POCUS programs long term. Each individual component, documentation, image archiving, billing, and coding is necessary to incorporate into a POCUS workflow as documentation, archiving, and coding of studies are required for appropriate billing. Most importantly, incorporating these practical components creates opportunities for communicating clinically relevant findings among care teams and enhances the quality of patient care delivered in health systems. As point-of-care ultrasound (POCUS) is increasingly implemented into the routine clinical practice of nephrologists, it is important to consider the practical aspects of a POCUS workflow including documentation, image archiving, billing, and coding. Documentation of POCUS studies performed allows for accurate information exchange among all members of the care team and can be effectively implemented using preset documentation worksheets. Image archiving systems provide a mechanism for review, storage, and quality assurance processes that are directly linked to the patient's record. Understanding the coding components required for billing and developing efficient systems to support billing and coding can contribute to ensuring financial support for POCUS programs long term. Each individual component, documentation, image archiving, billing, and coding is necessary to incorporate into a POCUS workflow as documentation, archiving, and coding of studies are required for appropriate billing. Most importantly, incorporating these practical components creates opportunities for communicating clinically relevant findings among care teams and enhances the quality of patient care delivered in health systems. Clinical Summary•Point-of-care ultrasound programs should consider developing and supporting a point-of-care ultrasound workflow that incorporates efficient and effective mechanisms of documentation, image archiving, billing, and coding.•A point-of-care ultrasound workflow that includes the aforementioned components has many benefits to patients, providers, and health systems including appropriate reimbursement for the time and expertise of the clinician as well as supporting high-quality patient care. •Point-of-care ultrasound programs should consider developing and supporting a point-of-care ultrasound workflow that incorporates efficient and effective mechanisms of documentation, image archiving, billing, and coding.•A point-of-care ultrasound workflow that includes the aforementioned components has many benefits to patients, providers, and health systems including appropriate reimbursement for the time and expertise of the clinician as well as supporting high-quality patient care. Critical to the development of a robust point-of-care ultrasound (POCUS) program are the practical aspects of documentation, image archiving, billing, and coding. Careful considerations into these components have a number of benefits for patients, providers, and the healthcare system.1Kessler R. Stowell J.R. Vogel J.A. et al.Effect of interventional program on the utilization of PACS in point-of-care ultrasound.J Digit Imaging. 2016; 29: 701-705Crossref Scopus (5) Google Scholar An established workflow that accounts for how to translate image acquisition to interpretation and clinical decision-making is essential. This workflow must consider image acquisition, interpretation, image archiving, and integration with the patient's medical record. In addition, this workflow includes a process for quality assurance which can be carried out by individuals trained in POCUS. A robust system alleviates the issues associated with phantom scanning, illiterate scans, and blind scans.2Hughes D. Corrado M.M. Mynatt I. et al.Billing I-AIM: a novel framework for ultrasound billing.Ultrasound J. 2020; 128Crossref Scopus (6) Google Scholar Phantom scans are ultrasound images that are performed by a provider without documentation or image acquisition (saving of images); illiterate scans are images that are saved without corresponding documentation; and blind scans are documented examinations without image acquisition. Each of these scenarios can be potentially dangerous for patient care as they represent a breakdown in the communication between the individual performing the examination and other providers who may be involved in the patient's care. There are many benefits to patients and providers when performing bedside POCUS including expedited time to diagnosis, assistance with medical decision making and therapeutic intervention, reduction in procedural complications, reduction in length of stay, and decreased patient care costs.2Hughes D. Corrado M.M. Mynatt I. et al.Billing I-AIM: a novel framework for ultrasound billing.Ultrasound J. 2020; 128Crossref Scopus (6) Google Scholar,3Soremekun O.A. Noble V.E. Liteplo A.S. Brown D.F.M. Zane R.D. Financial impact of emergency department ultrasound.Acad Emerg Med. 2009; 16: 674-680Crossref PubMed Scopus (15) Google Scholar Without an accompanying robust workflow, these benefits may not be recognized by other members of the care team and may not be communicated throughout the patient's encounter. Additional benefits of a robust workflow includes a quality assurance program that allows for following up patients owing to errors in interpretation, incidental findings, and more generally, offers opportunities for institutional quality improvement, overall supporting the delivery of high quality and safe patient care.1Kessler R. Stowell J.R. Vogel J.A. et al.Effect of interventional program on the utilization of PACS in point-of-care ultrasound.J Digit Imaging. 2016; 29: 701-705Crossref Scopus (5) Google Scholar Finally, from an institutional perspective, the benefits of an integrated workflow allow for improvements in resource utilization by minimizing costly and invasive procedures and capture services conducted by providers that are a potential source of revenue and reimbursement. Providing accurate and accessible real-time documentation with interpretation is a critical component of relaying timely information to members of the care teams and assessing therapeutic interventions across the care continuum. Ideally, all members of the care team are able to view documentation and saved images in real time as well. Incomplete and inaccurate documentation creates challenges for clinical care but also limits billing and thus reimbursement. There are a number of elements that should be included in documentation. For billing purposes, requirements include the indication for the study, a written report, and interpretation.4American College of Emergency PhysiciansUltrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.https://www.acep.org/Clinical-Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1Date: 2016Google Scholar The description of findings and interpretation is ideally completed immediately after the study is performed for clinical and billing efficacy. Creating preset documentation worksheets for common studies will assist clinicians with documentation necessary for clinical care and for billing. The following are items to include when documenting each POCUS study (see Table 1, Documentation of POCUS Studies, see Fig 1 Example Documentation).5American Institute of Ultrasound in Medicine (AIUM)AIUM Practice parameter for documentation of an ultrasound examination.J Ultrasound Med. 2020; 39: E1-E4Google Scholar, 6Pinson R.D. Point-of-care ultrasound-Part 1. ACP hospitalist.https://acphospitalist.org/archives/2020/03/coding-corner-point-of-care-ultrasound-part-1.htmGoogle Scholar, 7American College of Emergency PhysiciansUltrasound coding and reimbursement document.https://www.acep.org/globalassets/uploads/uploaded-files/acep/membership/sections-of-membership/ultra/running-a-program/coding.pdfDate: 2009Google ScholarTable 1Documentation of POCUS Studies1.Patient information including name, date of birth, patient ID/medical record number2.Provider performing the ultrasound and provider interpreting the ultrasound3.Date and time of ultrasound4.Clinical or educational scan5.Limited vs complete vs procedural6.Indication for the study7.Acquisition including views obtained8.Description of findings, structures evaluated/relevant anatomy, abnormal findings9.Interpretation10.Comparison to previous images (if applicable)11.Follow-up studies (if applicable)12.SignatureAbbreviation: POCUS, point-of-care ultrasound. Open table in a new tab Abbreviation: POCUS, point-of-care ultrasound. Depending on the workflow of the department and/or institution, this information can be obtained using a scanning system connected to the ultrasound machine so the patient's barcode can simply be scanned into the system. Another option is to connect the archival system to the electronic health record (EHR) so the patient's information can be manually searched in the worklist. Ensure the individual performing and/or interpreting is credentialed appropriately as per departmental/institutional/specialty requirements.8Koratala A. Segal M.S. Kazory A. Integrating point-of-care ultrasound into nephrology fellowship training: a model curriculum.Am J Kidney Dis. 2019; 74: 1-5Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar This is typically automatically included when the images are saved providing the ultrasound machine date/time is accurate. At many institutions, trainees may be engaging in educational activities. While these studies may still undergo quality assurance as part of departmental policies, they are not typically intended for clinical decision-making. Documenting this is important to ensure the studies are not submitted for billing and coding. Most bedside studies will be limited studies as a complete exam includes all anatomical structures in a specific region being evaluated. For procedural documentation, it's helpful to include at least one image either before or after the procedure to localize the site and real time if possible. The note should also document whether the procedure was ultrasound assisted, used for visualization, and/or ultrasound guided as this would be 2 separate charges. Specifically for vascular access, providers must document the site, vessel patency, and record the needle in the vessel in real time. The indication for the examination is important to document as it highlights the medical necessity for the POCUS study, can be linked to an International Classification of Diseases (ICD-10) code and thus can be used for billing/coding purposes. This includes documenting what views were acquired and if any were technically limited or inadequate with an accompanying explanation. Describe what structures were or were not visualized, measurements obtained, normal and/or abnormal findings. The interpretation should clarify whether the study was normal or abnormal, provide an assessment of the findings, and establish how this contributes to medical decision-making. Indicate if prior images were obtained and comparison to priors, including whether the interpretation has changed. Indicate whether a complete ultrasound is indicated after the limited study is performed. It is essential to ensure that a system exists for permanently storing/archiving the images that is linked to the patient's medical record. For billing purposes, there is not technically a predetermined type or number of images that must be saved; however, it is helpful to establish institutional or departmental guidelines for the purpose of standardization. For example, obtaining 4 views for a bedside echo study including parasternal long, short, apical 4, and subxiphoid. It is important to remember to sign and, if applicable, submit images and interpretation if required for billing. Image capture and storage is required for all POCUS studies including procedural studies. Images should be permanently stored and linked to the patient's record. In addition to reimbursement requirements, image storage is beneficial as it allows for other members of the care team to view images and for quality assurance which is a key component of any program. While the number and types of images are not specified, ideally structures are visualized in 2 planes with corresponding labels, demonstrating relevant structures/pathology, relevant measurements, and abnormal findings.4American College of Emergency PhysiciansUltrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.https://www.acep.org/Clinical-Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1Date: 2016Google Scholar There are a number of options for image archival. Historically, images were printed or stored via a USB drive. We have now progressed to digital/web based systems, which are preferred and have the option for integration to the Picture Archiving and Communication System (PACS). Often ultrasound companies and/or machines may have their own dedicated cloud or archival system. There are advantages and disadvantages to all systems and it's important that the system implemented works effectively with existing hospital systems—specifically, dedicated radiology archiving systems. There are multiple additional considerations when choosing a system, which includes how it affects the program's workflow for billing, quality assurance, and education. The American Institute of Ultrasound in Medicine position statement concludes that, "any qualified physician who interprets an indicated, appropriately performed, and documented ultrasound examination, should be allowed to bill for imaging services rendered."9American Institute of Ultrasound in Medicine (AIUM)Statement on ultrasound billing.https://www.aium.org/officialStatements/46Google Scholar The US Centers for Medicare and Medicaid Services guidance also supports reimbursement for performance and interpretation of POCUS examinations regardless of the specialty of the physician who is performing the service.10U.S. Centers for Medicare & MedicaidChapter 13: Medicare claims processing manual.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c13.pdfGoogle Scholar Therefore, if a POCUS study is performed and includes an official review process, the department can and should code and bill for POCUS studies.11Soni N.J. Schnobrich D. Mathews B.K. et al.Point-of-care ultrasound for hospitalists: a position statement of the society of hospital medicine. J Hosp Med.https://cdn.mdedge.com/files/s3fs-public/issues/articles/soni02780102e.pdfDate: 2019Google Scholar The requirements for billing include a medical indication for the exam, acquisition of images, saving and archiving images, and a report that documents the examination and provides an interpretation with appropriate billing and coding.2Hughes D. Corrado M.M. Mynatt I. et al.Billing I-AIM: a novel framework for ultrasound billing.Ultrasound J. 2020; 128Crossref Scopus (6) Google Scholar Most bedside POCUS studies performed will be limited or focused. A limited examination is defined as an ultrasound examination that has fewer than the required elements that would qualify for a complete examination and therefore does not attempt to visualize and evaluate all major structures within an anatomic region. For example, a complete ultrasound examination of the abdomen is defined as an evaluation of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the abdominal aorta and inferior vena cava. This complete examination would include images of every single organ and must attempt to diagnostically evaluate all of these organs. More realistically, a bedside examination may focus solely on the kidneys or a single quadrant of the abdomen and is considered a limited examination.4American College of Emergency PhysiciansUltrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.https://www.acep.org/Clinical-Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1Date: 2016Google Scholar POCUS studies can be performed for either diagnostic or therapeutic indications. In the event that a study is used to diagnose a previously unknown pathology and additionally is used for procedural guidance, both examinations can be billed on the same day. However, if ultrasound guidance discovers a previously unknown pathology, a separate diagnostic ultrasound should not be reported.12Centers for Medicare and Medicaid ServicesNational Correct coding initiative Edits.https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEdGoogle Scholar Typically, the documentation of procedural guidance is included in the documentation of the procedure itself and not as a separate report. Of note, POCUS is considered a procedure and therefore if billing for ultrasound, the time spent performing POCUS should not be included in time-based billing for critical care. In general, when serial POCUS examinatios are performed on the same patient on the same day, only one of these studies should be coded and billed. However, any serial examination can be billed for if there is clinical necessity for that subsequent scan. A modifier should be used if this is the case for a serial examination on the same day. Serial examinations on subsequent days can be billed without a modifier. When separate providers both perform the same examination, they both can bill for the examination using a modifier as long as there is documented medical necessity for the repeat examination. If a provider performs a limited examination and then subsequently determines a complete examination performed by radiology is required, the provider can still bill for the focused examination. In this case, the radiology study would generate a separate charge. In each of these instances, there must be documentation providing the medical necessity for the 2 separate examinations. It is not uncommon that a limited examination can be inconclusive or result in findings with clinical significance for which a complete examination is indicated. It should be noted that typically payers may only reimburse for the examination which answered the clinical question/indication. The caveat is that it would be inappropriate if a provider routinely performs a limited examination before ordering a complete examination. In addition, the same provider cannot perform both a limited and a complete examination. In this case, the limited examination would be considered included in the complete examination. Regardless, appropriate services should be coded based on the Current Procedural Terminology (CPT) codes with appropriate detail in the form of add-on codes or modifiers, and the decisions for reimbursement can be left to the insurer. While CPT codes do not define the number of images that should be obtained or stored, it does require that the images appropriately reflect the findings and interpretation documented in the report. In general, convention recommends capturing the object of interest in 2 orthogonal planes or classic windows if there is such convention. For procedural guidance, an image of relevant anatomy is sufficient with a report that specifies that the needle was guided and visualized with ultrasound.4American College of Emergency PhysiciansUltrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.https://www.acep.org/Clinical-Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1Date: 2016Google Scholar All ultrasounds performed have both a professional component and a technical component. The professional component encompasses the provider performing, interpreting, and documenting the examination. The technical component represents the cost of the equipment, supplies, and additional personnel needed to perform the examination. In general, the provider bills for the professional component and the hospital system or institution would bill for the technical component.13Flannigan M.J. Adhikari S. Point-of-care ultrasound work flow innovation: impact on documentation and billing.J Ultrasound Med. 2017; 36: 2467-2474Crossref Scopus (13) Google Scholar The exception would be if the individual also owns the equipment used for the ultrasound examination. To bill for a POCUS study, appropriate codes should be applied that describe the procedure performed and indication. The CPT Editorial Panel, convened by the American Medical Association, defines a set of codes that allow for uniform description of exams performed.14American Medical AssociationCPT® overview and code approval.https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approvalGoogle Scholar Billing claims are submitted using specific CPT codes, and codes can include a modifier or add-on to better describe what was performed. CPT codes are universal and thus the same for all providers regardless of specialty or practice setting.4American College of Emergency PhysiciansUltrasound guidelines: emergency, point-of-care, and clinical ultrasound guidelines in medicine.https://www.acep.org/Clinical-Practice-Management/Ultrasound/#sm.0001wi32c84dcew4yrs2erxapx6h1Date: 2016Google Scholar See Table 2 for common CPT codes. Modifiers and add-on codes help to better define the exam or procedure performed.Table 2CPT Codes for Focused ExaminationsUS StudyCPT Code(s)DescriptioneFAST767059330876604Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-Mode recording; follow-up or limitedUltrasound, chest, B-scan (includes mediastinum) and/or real time with image documentationAorta – AAA screening76706Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysmTransthoracic echo93308Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-Mode recording; follow-up or limitedFocused DVT exam93971Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study.Pulmonary76604Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentationBowel76705Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)Renal76775Echography, retroperitoneal (eg renal, aorta, nodes); B-scan and/or real time with image documentation; limitedPostvoid residual (bladder)51798Measurement of postvoiding residual urine and/or bladder capacity by bladder volume measurement machineBladder imaging76857Imaging of bladder anatomy, including bladder volume measurement using an ultrasound machineSoft tissue – Neck76536Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with image documentationSoft tissue – MSK including axilla76882Ultrasound, extremity, nonvascular, B-scan and/or real time with image documentation, limitedSoft tissue – chest wall or upper back76604Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentationSoft tissue – abdominal wall or lower back76705Echography, abdominal, B-scan and/or real time with image documentation, limited (eg, single organ, quadrant, follow-up)Soft tissue – pelvic wall76857Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, limited, or follow-upAbbreviation: CPT, Current Procedural Terminology. Open table in a new tab Abbreviation: CPT, Current Procedural Terminology. To document the indication for a POCUS study, the examination or procedure should be associated with an ICD-10 code. The International Classification of Disease Procedures Coding System is an internationally standardized tool published by the World Health Organization that defines the patient's diagnosis, signs, symptoms, or abnormal diagnostic test and is used by payers to determine the medical necessity for services provided.7American College of Emergency PhysiciansUltrasound coding and reimbursement document.https://www.acep.org/globalassets/uploads/uploaded-files/acep/membership/sections-of-membership/ultra/running-a-program/coding.pdfDate: 2009Google Scholar Payors can publish bulletins known as Local Coverage Determinations which help better define certain ICD-10 codes that will support specific procedures defined by their CPT codes.15Moore C.L. Credentialing and reimbursement in point-of-care ultrasound.Clin Pediatr Emerg Med. 2011; 12: 73-77Crossref Scopus (9) Google Scholar However, these are often difficult to find and nongovernment organizations are not required to make these bulletins public. In addition, which ICD-10 codes are associated with any particular CPT code can vary between states.16Koenig S.J. Lou B.X. Moskowitz Y. et al.Ultrasound billing for intensivist.Chest. 2019; 156: 792-801Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Modifiers are used to better describe what was performed without changing the definition of the code. See Table 3 for common modifiers. Modifiers can distinguish between complete and limited examinations or professional and technical components of an examination. Of note, there are CPT codes in which no corresponding limited procedure exists. If this is the case, the service reduction modifier -52 can be used. When coding, if both the professional and technical components are performed by the provider, no additional modifier is required. However, if only the professional or technical component is performed by the provider, a modifier (-26 for professional component and -TC for technical component) should be used to explain this.Table 3CPT Code ModifiersModifierDescriptionExplanation-25Evaluation and management serviceUsed for any evaluation and management service provided on the same day as the POCUS-26Professional component (PC)Used for the performance and interpretation of the exam and completing a written report-TCTechnical componentUsed for the equipment, supplies and ancillary personnel associated with an exam-52Reduced servicesDescribes that the typical procedure was not performed as described but at some reduced level of service. This is used for limited ultrasounds where there's not a separate CPT code for a limited exam.-59Distinct Procedural ServiceUsed to report procedures that are distinct but have the same CPT code-76Repeat procedure by same providerDescribes a repeat exam by the same provider. All providers in the same specialty or same medical group/employer during the same encounter are viewed as the same provider.-77Repeat procedure by different providerDescribes a repeat exam by a different providerAbbreviations: CPT, Current Procedural Terminology; POCUS, point-of-care ultrasound. Open table in a new tab Abbreviations: CPT, Current Procedural Terminology; POCUS, point-of-care ultrasound. Some CPT codes for procedures include both the POCUS study and procedure and do not require separate coding for the POCUS study. However, if this is not the case, and the POCUS study requires a separately coded item, add-on codes 76942 and 76937 can be used. These codes should be assigned along with the procedure code and not assigned alone. They are used when the CPT code itself does not describe ultrasound guidance. For example, code 32555 is used specifically for ultrasound-guided thoracentesis and therefore does not need an add-on code. However, code 36556 defines nontunneled central venous catheter insertion (including those used for dialysis). If the insertion was performed in a dynamic technique under ultrasound guidance, then the add-on code 76937 should be used. If ultrasound was used to identify the anatomy but not used for real-time needle guidance (as in a static approach), then the add-on code 76937 should not be used. In addition, some POCUS examinations do not have a single associated CPT code. In the case of an E-FAST performed in a patient who is hypotensive, the examination will be coded for each of the anatomic locations where the examination was performed. This generates 3 distinct codes: cardiac (93308), abdomen (76705), and chest (76604). See Table 4 for procedural codes and Fig 2 for a sample billing scenario.Table 4CPT Codes for Ultrasound-Guided ProceduresProcedureCPT CodeAdditional CommentsThoracentesis32555Thoracentesis, needle or catheter, aspiration of the pleural space, with image guidanceThoracentesis with catheter placement32557Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidanceParacentesis49083Abdominal paracentesis (diagnostic or therapeutic); with imaging guidancePeritoneal catheter insertion49418Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed and radiological supervision and interpretation, percutaneousUltrasound-guidance of vascular procedures+ 76937Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting. This is an addon code and requires primary code.Arterial puncture+ 76937This is an addon code and requires primary code 36600US-guided vascular access placement+ 76937This is an addon code and requires primary code: 36000 (venipuncture or catheter placement), 36410 (venipuncture, >age 3 requiring physician expertise),36555 (nontunneled CVC, age <5), 36556 (nontunneled CVC, age >/ = 5), 36557 (tunneled CVC, age<5), or 36558 (tunneled CVC, age >/ = 5)Ultrasound-guided needle placement (nonvascular)+ 76942Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. This is an addon code and requires primary code.US-guided incision and drainage or aspiration of abscess+ 76942This is an addon code and requires primary code: 10160 (simple) or 10061 (complicated)US-guided suprapubic aspiration of bladder+ 76942This is an addon code and requires primary code: 51100US-guided incision and removal of foreign body+ 76942This is an addon code and requires primary code: 10120 (simple) or 10121 (complicated)US-guided renal biopsy+ 76942This is an addon code and requires primary code: 50200Abbreviation: CPT, Current Procedural Terminology. Open table in a new tab Abbreviation: CPT, Current Procedural Terminology. To appropriately bill and code for an ultrasound study, images must be archived and documented using required documentation standards. The financial implications of an ultrasound program are important to consider, as implementation of an ultrasound program is costly. One study demonstrated that programs will "break even" around 5 years after implementation which supports the need for documentation and billing/coding at initiation or soon after.3Soremekun O.A. Noble V.E. Liteplo A.S. Brown D.F.M. Zane R.D. Financial impact of emergency department ultrasound.Acad Emerg Med. 2009; 16: 674-680Crossref PubMed Scopus (15) Google Scholar Prior emergency department based studies indicate that while there is a high utilization of ultrasound, documentation has lagged behind, which is essential for reimbursement and high-quality clinical care.2Hughes D. Corrado M.M. Mynatt I. et al.Billing I-AIM: a novel framework for ultrasound billing.Ultrasound J. 2020; 128Crossref Scopus (6) Google Scholar Incorporating and emphasizing documentation early on is critical to the success and sustainability of an ultrasound program so providers are reimbursed for their time and expertise and supported by the hospital system. In addition, completing regular fiscal analyses of programs will assist in evaluation of actual and potential return on investment. As POCUS adoption and implementation continues to expand throughout hospital systems, it has become increasingly important to consider infrastructure that facilitates documenting, archiving, and billing/coding that is incorporated efficiently into the EHR. One study highlighted workflow infrastructure that incorporates an image archiving system, Qpath US work flow solution (Telexy Healthcare, Maple Ridge, British Columbia, Canada), a dedicated ultrasound machine, Zonare Z.One ULTRA ultrasound system (Mindray, Mountain View, CA), and an EHR system, Cerner. The integrated system automates documentation and billing, and images are automatically transferred to the hospitals archiving system picture archiving and communication system and EHR. After implementation of this process, there was a significant increase in billing, specifically a 96% increase in net technical revenue and a 78% increase in professional revenue.13Flannigan M.J. Adhikari S. Point-of-care ultrasound work flow innovation: impact on documentation and billing.J Ultrasound Med. 2017; 36: 2467-2474Crossref Scopus (13) Google Scholar Similarly, another study demonstrated improvement in billing and revenue after implementation of a web-based archival system, Qpath, with automatic image transfer and immediate completion of worksheets linked to specific CPT codes.17Adhikari S. Amini R. Stolz L. et al.Implementation of a novel point-of-care ultrasound billing and reimbursement program: fiscal impact.Am J Emerg Med. 2014; 32: 592-595Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Simply creating a dedicated workflow task force has also demonstrated improvements in documentation compliance and coding and billing.18Lewiss R.E. Cook J. Sauler A. et al.A workflow task force affects emergency physician compliance for point-of-care ultrasound documentation and billing.Crit Ultrasound J. 2016; 85Crossref PubMed Scopus (11) Google Scholar There are many benefits of POCUS implementation for patient, providers, and health systems. While the focus of bedside ultrasound has appropriately targeted education and training, equally important is ensuring a process for acquisition, documentation, image archiving, coding, and billing in conjunction with institution-specific systems and requirements. Developing an integrated workflow at the start of program implementation is critical for patient safety and sustainability of POCUS programs.