Shuchi K. Rodgers, MD, FSRU
Section Chief, Abdominal Imaging
Director of Ultrasound
Department of Radiology, Einstein Medical Center
Clinical Associate Professor of Radiology
Sidney Kimmel Medical College at Thomas Jefferson University
Question: I am interested in starting a contrast enhanced ultrasound (CEUS) program at my hospital. What are the CEUS current procedural terminology (CPT) codes and work relative value units (RVU)? What are the basics of getting started and tips for beginners?
Answer: Congratulations on your role as the CEUS champion at your institution – the first step in starting a program! To quickly review, CEUS is an FDA approved imaging technique using microbubbles for evaluation of a focal liver lesion in an adult or pediatric patient. CEUS can be used off-label to determine enhancement characteristics of a variety of lesions throughout the body. Advantages include: continuous imaging of the arterial phase (no ‘missing the bolus’), no ionizing radiation, low cost, no nephrotoxicity (can be performed in patients with renal insufficiency), and one can perform multiple injections in one exam. Disadvantages of CEUS include: unable to be used for tumor staging, assesses one or few lesions at a time, not all lesions suitable for CEUS, and requires higher level of expertise. A summary of the steps used in starting our practice is listed in Table 1 and other excellent resources are available (1,2).
CEUS work RVU and CPT codes were updated in November 2018 and are effective January 1st, 2019 and are listed in Table 2. Unlike CT and MRI studies with contrast where a single CPT code covers with and without (w/wo) intravenous contrast, the new CEUS CPT codes are add-on, and are to be combined with existing B-mode ultrasound and/or Doppler CPT codes (3). CPT 76978 is for an initial CEUS injection with a work RVU of 1.62 and CPT 76979 is for a subsequent injection with a work RVU of 0.85. The codes are agent agnostic (can be used with any agent, not limited to Lumason) and organ agnostic (any organ, not limited to the liver). CEUS has a Medically Unlikely Edit (MUE) of 3 – indicating that a radiologist can bill for four contrast injections in one day; one initial (CPT 76978) and three additional (CPT 76979) injections. However, as a vial of Lumason contains 5 ml and the standard recommended dose for a liver lesion is 1.8 – 2.4 ml and for a kidney lesion is 1.8 – 2.0 ml, typically one can perform up to 3 injections with one vial of Lumason. An example of the total work RVU of a CEUS study that evaluates two focal liver lesions with two different injections: US abdomen limited (RVU 0.59) + US CEUS initial injection (RVU 1.62) =2.21 + subsequent injection (RVU 0.85) = 3.06. For comparison, a CT abdomen w/wo contrast work RVU is 1.40 and an MRI Abdomen w/wo contrast work RVU is 2.20. Other comparison work RVU for different radiology studies is listed in Table 3.
Although renal CEUS is considered off-label, the kidney is the best organ to evaluate when starting a CEUS program as the imaging findings are straightforward and often binary (yes or no enhancement) (4). In our practice, we perform predominantly liver and kidney CEUS, but have also evaluated the bowel, urinary bladder, hematomas for active bleeding or vascularity, vessels for tumor in vein versus bland thrombus, and the cervix (5,6). Indications for CEUS also include any focal indeterminate finding on CT, MRI, or non-contrast US, or a focal lesion in a patient with renal insufficiency or contrast allergy. A table listing our CEUS procedure is listed in Table 4. Our program started in January 2017 and while we had on-site support for our initial studies, our learning curve elucidated several common pitfalls, which are listed with troubleshooting tips in Table 5 (7).
In summary, CEUS offers numerous advantages including a low adverse reaction rate, non-ionizing test with no nephrotoxicity, and the ability to perform multiple contrast injections. Successful integration of CEUS into a radiology practice adds considerable value particularly for the indeterminate focal lesion in a renal insufficiency patient. Building a successful CEUS practice requires patience and perseverance, but the tools and information presented here can expedite the process and minimize pitfalls.
Steps to Start a CEUS Practice | Description |
Designate a Radiology CEUS Champion | This individual drives the entire process |
Procure Contrast Software on Ultrasound Unit | One to two ultrasound units |
Procure Contrast Agent | Present contrast agent at pharmacy committee for approval if not already on formulary |
Establish a CEUS Protocol in Radiology | List the steps of the CEUS protocol and obtain approval from radiology administrator |
Designate and Train Sonographer(s) | Send sonographers to training courses |
Create Radiology Exam(s) in Radiology Information System | Create exam codes for clinicians to order the test, include up to date CPT coding |
Educate Colleagues and Referring Physicians | Teach colleagues how and when to recommend CEUS, as volume grows teach/train colleagues; CEUS champion can give grand rounds to referring physicians |
Determine the Logistics of Ordering the CEUS study | Determine best process for scheduling CEUS study based on CEUS Radiologist Availability |
Outline the Logistics of Procedure and Image Archiving | Determine who places IV and injects the contrast. Protocol based on organ imaged (liver, kidney, bowel, endoleak). Determine image archiving – send entire Cine loops to PACS versus selected images only |
Create a Reporting Template | Standard report template based on organ imaged and should include at a minimum: study adequacy, contrast/injection event, presence or absence of enhancement; for liver nodules also include type of enhancement (centrifugal, centripetal, peripheral discontinuous, dysmorphic), and presence or absence of washout. |
First CEUS Study | Representatives from both Ultrasound Contrast Agent and Ultrasound Vendor should be present to aid in mixing/injecting of contrast and machine knobology |
Perform Continual Quality Assurance | Follow-up on all cases to ensure diagnostic accuracy, and identify any issues. Obtain regular software updates and inservices from ultrasound vendor |
Table 1: Steps to Start a CEUS Practice
CEUS Procedural Terminology (CPT) and Relative Value Unit (RVU) effective 1/1/ 2019 |
Two new stand-alone codes for CEUS (CPT 76978 and CPT 76979) · Codes are agent agnostic (any agent, not limited to Lumason) · Codes are organ agnostic (any organ, not limited to the liver) · Unlike CT/MR contrast codes where a single code covers with/without, new CEUS codes are piggybacked onto existing grayscale and/or Doppler US codes · Most common grayscale codes: US abdomen limited – CPT 76705 or US retroperitoneal limited (renal) – CPT 76775 · Medically Unlikely Edit (MUE) 3 – can bill for four contrast injections in one day; one initial (CPT 76978) and three additional (CPT 76979) |
CPT 76978, initial CEUS injection, work RVU 1.62 • Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion |
CPT 76979, each subsequent injection if evaluating multiple lesions, work RVU 0.85 • Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac) • List each additional lesion with separate injection in addition to code for primary procedure • These can be in different organs |
Table 2. CEUS CPT Code and work RVU
Radiology Study | CPT code | Work RVU |
MRI Abdomen with/without (w/wo) contrast | 74183 | 2.20 |
CT Abdomen w/wo contrast | 74170 | 1.40 |
CT Abdomen and pelvis w/ contrast | 74177 | 1.82 |
MRI Extremity w/ contrast | 73722 | 1.62 |
US Abdomen complete | 76700 | 0.81 |
US Abdomen limited | 76705 | 0.59 |
US Doppler | 93975 | 1.16 |
US Retroperitoneal limited | 76775 | 0.58 |
US CEUS initial injection | 76978 | 1.62 |
US CEUS subsequent injection | 76979 | 0.85 |
Table 3. Comparison CPT and Work RVU of different Radiology Studies
CEUS Procedure at Einstein Medical Center |
1. Patient arrives for CEUS. Review prior imaging to determine best sonographic approach. |
2. Perform B-mode and Doppler ultrasound of area of interest. |
3. Best to have area of interest within 10-15 cm of depth and in sagittal plane to minimize out of plane from respiratory motion, this may require LPO or creative positioning. |
4. If suspended respiration required to visualize area of interest, sonographer should practice breathing instructions with patient before injection. Better to have only one person giving instructions. For suspended respiration during routine breathing, better to tell patient “stop breathing” rather than “hold your breath”, as the latter can result in a deep inhalation prior to breathhold. We generally start breathhold 8 seconds post injection. |
5. Use optimal contrast transducer and setting – check with manufacturer. |
6. Sonographer shows images to radiologist; occasionally question can be answered on non-contrast US and contrast study is cancelled. |
7. A 20 gauge (or 22 gauge) intravenous catheter placed preferably in left antecubital fossa |
8. Sonographer fills out contrast screening for which is used to identify contraindications and lists location and gauge of IV. |
9. Radiologist or designee attaches 3-way stopcock, flushes IV, and prepares ultrasound contrast. |
10. Radiologist or designee attaches contrast syringe parallel to tubing and saline flush perpendicular to tubing |
11. Sonographer selects dual screen Contrast/low MI B-mode setting |
12. Radiologist or designee bolus injects contrast followed by saline flush (contrast timer initiated at onset of saline flush), and sonographer starts cine loop |
13. For liver lesions, we obtain a continuous one minute cine and then freeze and keep transducer on the patient over area of interest; simultaneously we scroll back the cine and acquire representative images of arterial and portal venous phases; lesion is measured on the side where it is best seen (contrast or low MI B-mode), using a ‘copy’ mode, which then automatically measures the lesion on the other screen. |
Table 4. CEUS Procedure at Einstein Medical Center
CEUS Pitfall | Solution/Troubleshooting |
Excessive bubble destruction | Ensure satisfactory flushing of IV line and practice maneuvering 3-way stop cock prior to injecting contrast; minimize continuous scanning directly over area of interest in order to minimize bubble destruction |
Inadequate visualization of target lesion | Optimize lesion depth and visualization prior to injection; if it is not well seen on high MI B-mode images, it will not be seen with contrast. Make sure that the optimal contrast settings are utilized which may require discussion with ultrasound manufacturers. |
Inability to visualize known findng (as seen on prior CT or MRI) on ultrasound | Use first contrast injection to localize the observation (which may be visualized as an area of washout in cases of suspected malignancy). If it is seen, repeat technique on subsequent injection to determine pattern of arterial phase enhancement |
Missed pattern of arterial phase hyperenhancement (APHE) or unclear if there is enhancement of a lesion | Use bubble destruction and reperfusion technique (i.e., FLASH) in order to re-assess pattern of arterial enhancement and/or perfusion |
Missed APHE in suspected malignancy due to respiratory motion | Repeat injection; try sagittal plane which minimizes out of plane motion; practice breathing instructions in order to keep lesion in view during entire arterial phase (use ‘stop breathing’ instead of ‘hold your breath’) |
High contrast dose/saturation effect | For subcapsular lesions and in very thin patients, standard contrast doses can be too high and can result in marked enhancement in the near field resulting in significant posterior acoustic shadowing; use less contrast volume in these patients |
How to assess a liver nodule for washout if the nodule becomes inconspicuous (isoenhancing and isoechoic) after injection | Use internal landmarks to localize region of interest; mark skin on patient to ensure return to similar scanning region; freeze image in between cine loops and keep transducer over area of interest during the entire liver scan |
Table 5. List of common CEUS pitfalls with troubleshooting tips
Bibliography:
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2. Weinstein S, Jordan E, Goldstein R, et al. How to set up a contrast-enhanced ultrasound service. Abdominal Radiology 2018;43(4):808-818.
3. CMS Medicare Physician Fee Schedule Look-Up Tool. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html.
4. Harvey CJ, Alsafi A, Kuzmich S, et al. Role of US Contrast Agents in the Assessment of Indeterminate Solid and Cystic Lesions in Native and Transplant Kidneys. RadioGraphics 2015; 35:1419-1432.
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