(Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation)
Documentation requirements are gaining momentum for ultrasound guidance, 76942. No longer can we expect limited notations such as “under ultrasound guidance” to survive a payer audit. Like most radiology codes, there must be enough information to satisfy the requirements of an interpretation and report. In other words, being paid separately requires a distinct and detailed description of how the ultrasound was used as a guide.
Though CPT does not include specific guidelines as to what has to be documented, the interpretation should clearly state visualization of the needle after penetration of the skin. The following excerpt from CPT® Assistant helps to outline what should be documented in an ultrasound note for a 76937 for venous access: “This imaging includes pre-access assessment of venous patency and actual real-time visualization of needle passage to the venous lumen.”
While the above addresses vascular access procedures, prudent documentation habits would dictate that the same guidelines for needle guidance (76942) should apply; visualization of the needle, noting landmarks, confirming the endpoint for aspiration or injection, or the spread of medication, etc.
Though documenting separately may seem demanding at first thought, it can still be as simple as:
Documentation templates can assist in achieving adequate documentation, just use them with caution. Unedited templates that are inconsistent with the clinical picture become suspect under audit. Make sure they prompt for patient/case specifics and accurately represent the work that took place.
What documents should be submitted under audit? The short answer is; any and all that support the charges! Keep in mind, ultrasound codes require that the images be retained and that they be producible to the payer upon request. abeo Advisory Solutions has seen this in action. Medicare demanded thousands of dollars in repayment when a practice did not send in the images to support their charges. Once the images were submitted through the appeal process, the practice was able to retain their payments, but not after a lot of hard work and heartache!
Ensure your practice’s EHR is able to retain and produce the images. For those services done at a facility, confirm there’s a fluid process for obtaining a copy. Understand the steps and even consider periodically testing the process, after all, they’re your charges at risk.
When it comes to US guidance for central venous and peripheral vascular access, there are unique and specific requirements for the code:
First, the code should only be reported 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 (or the anatomy) but is not used during line placement. CPT Assistant provides a non-billable example; “…for those instances when ultrasound is utilized only to identify a vein, mark a skin entry point, and proceed with a non-guided puncture, it would not be appropriate to report code 76937 for ultrasound guidance.”
In the dynamic technique, the physician uses ultrasound throughout the procedure, from the initial identification of the vessel through direct visualization of the needle entering the vessel. According to CPT Assistant, the code represents the work in “pre-access assessment of venous patency and actual real-time visualization of needle passage to the venous lumen… it includes all phases of actual guidance, documentation, and reporting required to perform this procedure.”
Secondly, like with 76942, the code “requires a permanent recorded image(s) of the vascular access site to be included in the patient record, as well as a documented description of the process either separately or within the procedure report.”
There seems to be an ongoing debate on whether 76937 should be billed along with the arterial line code, 36620. According to CPT’s parenthetical notes, there is no inclusionary relationship between the two codes. This is also supported by the lack of national correct coding initiative (NCCI) edits. Unless instructed otherwise by a payer, these two codes are reportable for the same operative session.
Physicians need to be proactive and invest in a process that monitors their coding accuracy and evaluates their documentation practices. Engage an organization with the expertise to audit, the skills to educate, and who demonstrates proven success with payer audits and appeals. Don’t let documentation pitfalls be the demise of your organization. That’s why abeo chooses the word “invest” when we refer to self-monitoring.
abeo Management Corporation (abeo) serves as a leading source of revenue cycle management and practice management with a specialization in anesthesia. The company leverages its people, processes, and software to serve independent practices, surgery centers, hospitals and healthcare systems with a scope of services that include billing, coding, transcription, practice management, and business consulting.