Documentation Tips

Documentation Tips: Ultrasound (Procedural US)

Documentation Tips: Ultrasound (Procedural US)

The keys to payment:

  • Medical necessity
  • Performing the entire service as described in CPT
  • Complete documentation equivalent to a specialist
  • Retained images

US codes typically require “permanently recorded images” and “a final written report.” “Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation and final, written report, is not separately reportable.” (New to CPT 2005)

If ultrasound guidance is used to complete a procedure it is generally appropriate to code for both the ultrasound guidance and the procedure performed. For example when performing an I&D of an abscess with ultrasound assistance, both the I&D 10061 and the ultrasound guidance for needle placement 76942-26 could be coded.

The keys to payment:

  • Medical necessity
  • Performing the entire service as described in CPT
  • Complete documentation equivalent to a specialist
  • Retained images

US codes typically require “permanently recorded images” and “a final written report.” “Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation and final, written report, is not separately reportable.” (New to CPT 2005)

If ultrasound guidance is used to complete a procedure it is generally appropriate to code for both the ultrasound guidance and the procedure performed. For example when performing an I&D of an abscess with ultrasound assistance, both the I&D 10061 and the ultrasound guidance for needle placement 76942-26 could be coded.

Common Procedural Guidance Ultrasounds Performed in the ED:

Ultrasound guidance for pericardiocentesis, imaging supervision and interpretation 76930 (-26)
Ultrasound 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 (List separately in addition to code for primary procedure) There are several unique aspects of the central venous and peripheral vascular access with ultrasound guidance code of which users must be aware. The first is that the code is intended for use only when the ultrasound is used with the “dynamic” technique, as opposed to the “static” technique which is not considered a reimbursable service. The static technique utilizes the ultrasound to identify the vessel, but is not used during line placement. In the dynamic technique the physician uses the ultrasound throughout the procedure from initial identification of the vessel through direct visualization of the needle entering the vessel. A permanently recorded image is required for coding 76937 (-26)
Ultrasound guidance for needle placement – use for paracentesis, thoracentesis, suprapubic aspiration, location of abscess for drainage (e.g., peritonsillar abscess) Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) imaging supervision and interpretation

(Do not use 76937 in conjunction with 76942)

76942 (-26)

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