There are several types of ultrasounds, and they’re usually covered by Medicare when ordered by your healthcare provider.
There may be an instance when your healthcare provider may order an ultrasound, as either a diagnostic test, to help advise on treatment, or assist during certain procedures. Read on to learn more about what Medicare beneficiaries need to know regarding Medicare benefits for ultrasounds.
What is an ultrasound?
A diagnostic ultrasound, also called a sonography or diagnostic medical sonography, is an imaging method that uses sound waves to produce images of structures within your body. These images can help with diagnosing and directing treatment for a variety of conditions and diseases, and can also assist surgeons during medical procedures.
During an ultrasound, the technician uses a small device called an ultrasound probe, which gives off high-frequency sound waves that bounce off the contours in the body and create echoes. These echoes are picked up by the probe and turned into a moving image that’s displayed on a monitor.
Most ultrasound scans last about 15 or 20 minutes and take place in a hospital or outpatient setting.
When is an ultrasound used?
Ultrasounds are used for a variety of reasons, such as to diagnose gallbladder disease, evaluate blood flow, examine a breast lump, assess joint inflammation, check the thyroid gland for abnormalities, guide a needle for a biopsy or tumor treatment, find genital and prostate problems, evaluate metabolic bone disease, and more.
Types of ultrasound scans
There are three types of ultrasound scans: External, internal, and endoscopic.
External ultrasounds are when a provider moves a handheld probe across the skin over the area that requires the exam. They will use a lubricating gel to ensure the probe moves smoothly and has continuous contact with the skin for an accurate image.
For internal ultrasound examinations, the provider will insert a small probe with a sterile cover. Typically, internal ultrasounds are used to examine internal organs, such as the prostate, ovaries, or uterus. While they may not be comfortable, they are rarely painful.
Finally, endoscopic ultrasounds are when a provider inserts an endoscope, typically through the mouth, to scan areas like the stomach and esophagus. The endoscope has an ultrasound probe and light attached to the end and works like any other ultrasound once inside the body. This typically happens under local anesthetic.
Medicare coverage for ultrasounds
Medicare will usually cover ultrasound tests as long as they are considered medically necessary and are ordered by your provider. They typically must be used as diagnostic imaging to diagnose a specific health condition, rule out a possible condition or illness, or examine and screen the body for potential medical issues.
The Centers for Medicare & Medicaid Services (CMS) dictates that ultrasounds that are clinically effective, usually part of initial patient evaluation, and may be adjunct to radiologic and nuclear medicine diagnostic techniques are typically covered.
So, if you get an ultrasound as part of an inpatient procedure, Medicare Part A (hospital insurance) will cover the exam. This includes inpatient settings like hospitals, medical centers, and skilled nursing facilities (SNF).
If the ultrasound is performed in an outpatient facility, such as your doctor’s office or health clinic, it is covered by Medicare Part B (medical insurance). The Part B deductible would apply, and you’d be responsible for 20% of the Medicare-approved amount.
Note if you choose to get an ultrasound that is not medically necessary or ordered by your provider, it likely will not be covered.
Medicare Part B also covers certain preventive services, including specific ultrasounds at no cost, such as abdominal aortic aneurysm screening ultrasounds (once in a lifetime if you’re at risk) and breast cancer screenings (screening mammograms once every 12 months if you’re aged 40 or older). Medicare Part B covers diagnostic mammograms more frequently if they are medically necessary, though you’d pay 20% of the Medicare-approved amount out-of-pocket (after meeting the Part B deductible). Medicare pays the other 80%.
If you have a Medicare Supplement plan (Medigap), it may help cover out-of-pocket expenses associated with getting an ultrasound, including deductibles, co-insurance, and co-pays.
Medicare Advantage plans (also known as Medicare Part C) must provide all the same benefits and coverage that Original Medicare does, so as long as the ultrasound is considered medically necessary and is ordered by your doctor, it will likely be covered by your Part C plan.
Some people choose to supplement their Medicare coverage with a Medigap plan instead of Medicare Advantage. In this case, your Medicare Supplement plan should cover most of your coinsurance. How much is covered depends on the plan.
You can compare Medicare Advantage, Part D, and Medigap plans easily with our Find a Plan tool. Just enter your zip code to compare costs and benefits of Medicare plans in your area.