Point-of-care ultrasound (POCUS) can be a valuable addition to a midwifery practice—but once a practice begins charging for ultrasound, the conversation quickly moves beyond the machine, training, and clinical workflow.

It moves into billing, coding, documentation, payer rules, compliance, and financial strategy.

This is an area where midwives need to be particularly careful.

A code that appears to describe an ultrasound service does not automatically mean a midwife can bill that code, a particular payer will reimburse it, or that the documentation supports its use.

For that reason, billing and coding should be approached as a practice-specific compliance issue, not simply a revenue opportunity.

Important: This article is intended for business education and is not billing, legal, or coding advice. POCUS billing rules can vary by state, payer, provider credentials, scope of practice, contract, and the exact service performed. Current CPT®, HCPCS, ICD-10-CM, payer policies, and applicable state and federal requirements should be verified before implementing a billing model.

At Midwifery Business Consultation, we encourage midwives to understand the business side of a service before adding it to their practice.

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Start With the Service—Not the Code

One of the most common billing mistakes is starting with:

“What code can I use for this ultrasound?”

Instead, start with:

“What service did we actually provide?”

Define the service first.

For example, your practice may provide a limited POCUS examination for a specific clinical question.

That is different from offering a comprehensive diagnostic ultrasound examination.

The distinction affects:

• Clinical expectations
• Documentation
• Training
• Scope
• Coding
• Billing
• Pricing
• Marketing

You cannot select an appropriate code until you have clearly defined what was actually performed.

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POCUS Is Not Automatically a Billable Service

This is an important concept.

The fact that a clinician performs an ultrasound does not automatically mean the service is separately billable.

Whether a service can be billed may depend on:

• The provider’s qualifications
• Scope of practice
• Payer policy
• Provider enrollment
• Contractual requirements
• Medical necessity
• The service performed
• Documentation
• Coding rules
• Whether the service is bundled into another service

Therefore:

“We performed an ultrasound” does not automatically equal “we can submit an ultrasound claim.”

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Know the Difference Between CPT and ICD-10-CM

At a basic level:

CPT®

CPT codes describe services and procedures performed.

ICD-10-CM

ICD-10-CM codes describe diagnoses, conditions, symptoms, or reasons for the encounter/service.

In a simplified example:

CPT: What did you do?

ICD-10-CM: Why was it medically appropriate to do it?

The two work together, but they are not interchangeable.

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Don’t Choose a Diagnosis Just to Make the Claim Pay

This is a major compliance issue.

A practice should not select a diagnosis code simply because it appears likely to result in reimbursement.

The diagnosis should accurately reflect the patient’s clinical situation and support the medical necessity of the service.

The rule should be:

Document the clinical reality first. Code what actually occurred.

Not:

Find a code that produces the desired reimbursement.

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Medical Necessity Matters

Payers generally expect a connection between the patient’s condition or clinical circumstances and the service performed.

That means your documentation should make it possible to understand:

Why was the ultrasound performed?

For example:

• What clinical question existed?
• What prompted the examination?
• What was the relevant finding?
• How did the result affect care?

Your documentation should tell the clinical story.

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Documentation Is the Foundation of Billing

If your documentation does not support the service, the claim may be difficult to defend.

Your POCUS documentation process should be designed before you begin billing.

Depending on the service and applicable requirements, documentation may include:

• Date
• Time
• Clinical indication
• Relevant history
• Examination performed
• Equipment/transducer used where appropriate
• Findings
• Images obtained
• Interpretation
• Clinical assessment
• Plan
• Referral or follow-up when indicated
• Clinician identification
• Appropriate consent documentation

The exact requirements depend on the service, payer, and applicable standards.

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“We Took a Picture” Is Not Sufficient Documentation

An image alone does not necessarily demonstrate the full clinical service.

Think about the difference between:

Image

and

Clinical examination + interpretation + documentation

If you intend to bill for a service, your documentation should support the service you are actually reporting.

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Understand Professional vs. Technical Components

Some diagnostic services can involve separate professional and technical components.

Conceptually:

Professional component

The professional work associated with performing/interpreting the service.

Technical component

The equipment, facility, supplies, and technical work associated with producing the study.

Whether and how these components apply to a particular ultrasound service depends on the specific code and billing circumstances.

Do not assume that every POCUS service should automatically be split into professional and technical components.

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Be Careful With Modifier Use

Modifiers can be important in medical billing.

But they should not be added simply because they increase reimbursement.

A modifier should be used only when the circumstances support its use and the applicable coding guidance permits it.

Your billing team or qualified coding professional should verify modifier requirements for the specific code and payer.

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Global Billing Rules Matter

Some services may have global billing rules or bundled components.

This means you need to determine whether the ultrasound service is:

• Separately billable
• Included in another service
• Subject to a global package
• Subject to payer-specific bundling

This is particularly important if the ultrasound is performed during a prenatal visit.

Do not automatically assume:

Prenatal visit + ultrasound = two separately payable services.

The relationship between services must be evaluated.

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Don’t Double-Bill for the Same Work

A practice needs to understand what work is already included in the primary service.

For example, if a particular ultrasound-related activity is considered part of another billed service under the applicable coding rules, separately billing it may create a compliance problem.

Before introducing a separate POCUS charge, determine:

Is this genuinely a separate service?

and

Is separate reporting permitted?

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Verify the Provider’s Eligibility to Bill

This is an area where midwifery practices need particular caution.

A code may exist.

A service may be clinically appropriate.

But that does not automatically mean every provider type can bill it under every payer.

Verify:

• Provider credentialing
• NPI requirements
• Payer enrollment
• Scope of practice
• State requirements
• Supervision requirements where applicable
• Payer-specific provider policies
• Contractual provisions

Your billing model must match the actual provider and practice structure.

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State Rules Matter

Midwifery practice is heavily influenced by state-specific law and regulation.

Requirements may differ regarding:

• Scope of practice
• Ultrasound
• Diagnostic imaging
• Supervision
• Delegation
• Ordering
• Interpretation
• Billing

Never assume that because another midwife in another state bills a particular service, your practice can do the same.

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Payer Policies Matter Even More Than You May Expect

Two insurance companies may treat the same service differently.

One payer may:

• Cover the service
• Require specific documentation
• Require credentialing
• Apply a particular reimbursement policy

Another may:

• Deny it
• Bundle it
• Require authorization
• Apply different provider rules

And your contract with a payer may contain additional requirements.

This is why a generalized online coding list should never be your only source.

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Medicare, Medicaid, and Commercial Insurance Are Not Identical

Do not build one billing assumption and apply it to every payer.

Your practice may interact with:

• Medicare
• Medicaid
• Medicaid managed-care plans
• Commercial insurers
• Self-pay clients

Each can have different requirements.

Even within Medicaid, managed-care organizations may have different administrative processes.

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Create a Payer Verification Matrix

One of the most useful business tools you can create is a payer matrix.

For example:

Do not populate this from assumptions.

Verify each item.

This becomes a living business document.

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Check Your Payer Contracts

If your practice participates with an insurance company, review the applicable agreement and payer policies.

Pay attention to provisions concerning:

• Covered services
• Reimbursement
• Coding
• Bundling
• Medical necessity
• Provider credentials
• Documentation
• Audits
• Overpayments
• Refund obligations

A billing strategy that looks profitable on paper may not work under your actual payer contract.

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Self-Pay Requires Its Own Strategy

If your practice offers POCUS to self-pay clients, establish the pricing and communication process in advance.

Your policy should clearly explain:

• What the service includes
• What it does not include
• The fee
• When payment is due
• Whether images are provided
• What happens if the examination is inconclusive
• When referral may be recommended

Transparency protects the client and the business.

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Don’t Market Self-Pay Ultrasound as a Substitute for Diagnostic Imaging

This is especially important.

If your POCUS service is limited, describe it accurately.

For example:

“This limited point-of-care ultrasound is performed for a specific clinical purpose within the scope of midwifery care. It is not intended to replace a comprehensive diagnostic ultrasound when one is indicated.”

The precise wording should reflect your actual service and applicable requirements.

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Build Your Pricing Around Your Costs

If you decide to offer self-pay POCUS, calculate your actual cost.

Consider:

Equipment

Training

Maintenance

Supplies

Clinician time

Documentation

Billing/administration

Insurance/risk management

Overhead

Profit margin

Your fee should be based on the economics of providing the service—not simply what another practice charges.

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Billing Revenue Is Not the Same as Collected Revenue

This is an important distinction for business owners.

Suppose you submit:

$200,000 in claims.

That does not mean your practice collected $200,000.

You need to monitor:

• Charges
• Payments
• Adjustments
• Denials
• Refunds
• Accounts receivable
• Collection rate

The number that matters to the business is ultimately what you actually collect.

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Track Your Denial Rate

If you begin billing POCUS, monitor denials carefully.

Create categories such as:

• Provider not eligible
• Service not covered
• Medical necessity
• Missing documentation
• Incorrect code
• Modifier issue
• Authorization
• Bundling
• Claim submission error

Patterns in denials can tell you where your process needs improvement.

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Don’t Automatically Write Off Denials

A denial is information.

If you receive multiple denials for the same reason, investigate.

For example:

Ten claims denied for missing documentation.

That may indicate a workflow problem, not a clinical problem.

Fix the process rather than simply writing off the revenue.

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Develop a Pre-Billing Checklist

Before submitting a POCUS claim, your billing workflow can include verification that:

• Correct provider is identified
• Correct date is documented
• Clinical indication is present
• Documentation supports the service
• Appropriate code selection has been verified
• Diagnosis coding reflects the record
• Required modifiers are supported
• Required images/documentation are retained
• Payer-specific requirements have been addressed

A checklist can prevent expensive recurring errors.

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Create a POCUS Documentation Template

A standardized template can make documentation more consistent.

For example:

POCUS Documentation

Indication:
[Clinical reason]

Examination performed:
[Specific limited examination]

Findings:
[Document findings]

Images:
[Document image acquisition/storage as applicable]

Interpretation:
[Clinical interpretation]

Clinical plan:
[Follow-up/referral/etc.]

Provider:
[Name/credentials]

The actual template should be designed around the service being provided and applicable requirements.

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Don’t Let the Template Create False Documentation

Templates are useful.

But templated documentation becomes dangerous when clinicians simply click through it.

For example:

“Normal.”

is not a substitute for documenting what was actually examined and found.

Templates should make accurate documentation easier—not manufacture documentation.

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Retain Images Appropriately

If your POCUS service includes image acquisition, establish an appropriate image retention process.

Consider:

• Where images are stored
• How images are linked to the patient’s record
• Who can access them
• How long they are retained
• How backups occur
• How privacy is maintained
• What happens when equipment is replaced

Image management is both a clinical and operational issue.

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Build a Compliance File

Consider maintaining a centralized POCUS file containing:

• Policies
• Training records
• Competency documentation
• Equipment information
• Maintenance records
• Payer policies
• Coding guidance
• Billing procedures
• Quality assurance records
• Revision history

This can be extremely useful if questions arise later.

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Don’t Let Your Billing Company Make Clinical Decisions

A billing company or coder can provide valuable expertise.

But the clinician remains responsible for accurate clinical documentation.

The business owner should understand:

What is being billed?

Why is it being billed?

What documentation supports it?

You should be able to explain your billing model without relying entirely on someone outside the practice.

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Conversely, Don’t Expect the Midwife to Know Every Coding Rule

The opposite extreme isn’t realistic either.

Medical coding is a specialized field.

If your practice begins submitting a significant volume of claims, consider obtaining appropriate professional coding and billing support.

The goal is not for the midwife to become a certified coder.

The goal is for the midwife-business owner to understand enough to manage the system intelligently.

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Perform a Pre-Launch Coding Review

Before your first claim, consider having your proposed workflow reviewed by an appropriately qualified professional.

For example:

Clinical scope review

→

Documentation review

→

Coding review

→

Payer verification

→

Billing workflow

→

Quality assurance

This is much less expensive than discovering after six months that your claims were structured incorrectly.

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Audit Yourself

Internal audits can be extremely valuable.

For example, review a sample of POCUS claims quarterly.

Ask:

Was the service actually performed?

Was the indication documented?

Does the documentation support the code?

Does the diagnosis reflect the record?

Was the correct provider identified?

Was the payer billed appropriately?

Were images retained as required?

Was the payment correct?

This is quality control for your revenue cycle.

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Watch for Overcoding

Overcoding occurs when the reported service is more extensive than what was actually provided.

This is not simply a “billing mistake.”

It can become a serious compliance issue.

Your business should have a culture of:

Accurate coding—not maximum coding.

The goal is to report the service correctly.

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Watch for Undercoding Too

The opposite problem can also occur.

If your documentation supports a service but your billing process consistently reports something less than what was appropriately performed, the practice may be losing legitimate revenue.

Good coding is not about maximizing or minimizing reimbursement.

It is about accurately representing the service.

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Keep Coding Resources Current

CPT® codes, payer policies, and reimbursement rules change.

Do not create a POCUS billing policy in 2026 and assume it will remain correct indefinitely.

Establish a review process.

At minimum, reassess when:

• CPT codes change
• Payer policies change
• Your service changes
• Your provider model changes
• Your state requirements change
• You add a new payer
• You change equipment or workflow

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Don’t Build Your Business Plan on a Coding Guess

This may be the most important business lesson.

Suppose your projected annual POCUS revenue is:

$60,000

But that number depends on a particular reimbursement assumption.

Before purchasing equipment, verify that assumption.

If the payer later reimburses substantially less—or denies the service—the entire business model can change.

Revenue projections should be based on verified assumptions.

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A Simple POCUS Financial Model

Consider building a spreadsheet with:

Revenue

• Expected number of scans
• Average allowed amount
• Expected collection rate
• Self-pay revenue

Direct Costs

• Supplies
• Staff time
• Billing fees

Fixed Costs

• Equipment
• Training
• Maintenance
• Software
• Insurance

Financial Metrics

• Revenue per scan
• Cost per scan
• Contribution margin
• Break-even volume
• Monthly cash flow
• Annual ROI

This allows you to answer the question:

Is POCUS actually making money?

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Know Your Break-Even Point

For example, suppose:

Annual fixed costs: $12,000

Average contribution per scan: $100

Then:

$12,000 ÷ $100 = 120 scans

You would need approximately 120 scans to cover those fixed costs under those assumptions.

But if your contribution is only $50 per scan, you would need:

240 scans.

Small changes in pricing, reimbursement, utilization, or expenses can dramatically affect your break-even point.

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Think About POCUS as Part of the Whole Practice

Sometimes the value of POCUS isn’t entirely captured by the ultrasound fee.

It may:

• Improve client retention
• Increase convenience
• Reduce outside referrals for appropriate limited assessments
• Differentiate the practice
• Improve client experience
• Increase perceived value
• Support a premium care model

Those benefits should be considered—but they should not be exaggerated.

Your business model should distinguish between:

Direct revenue

and

strategic value.

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The Biggest Billing Mistake: Thinking the Code Is the Business Model

A code is not a business strategy.

The business strategy is:

Clinical service

→ Qualified provider

→ Appropriate workflow

→ Documentation

→ Correct coding

→ Payer rules

→ Claim submission

→ Payment

→ Audit and quality assurance

Every link matters.

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Final Thoughts

Adding POCUS to a midwifery practice can create exciting clinical and business opportunities.

But the smartest approach is not:

“How much can we bill for ultrasound?”

It is:

“How can we provide an appropriate POCUS service, document it accurately, bill it correctly when permitted, and build a financially sustainable model around it?”

That requires midwives to think beyond the ultrasound machine.

It requires understanding:

Scope.

Training.

Documentation.

Coding.

Medical necessity.

Payer policies.

Pricing.

Collections.

Compliance.

Quality assurance.

And most importantly, clinical integrity.

A successful POCUS program should never be built around finding the highest-paying code.

It should be built around accurately representing the service you provide.

Document what you do.

Code what you document.

Bill only what is appropriately billable.

Verify what the payer allows.

And build the business model around verified information—not assumptions.

At Midwifery Business Consultation, we believe that financially successful midwifery practices are built when clinical excellence and business strategy work together.

The goal isn’t to bill more.

The goal is to build a POCUS service that is clinically appropriate, operationally sound, compliant, and financially sustainable.

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