Ultrasound Guidance Documentation Reminders

By Pam Linton, CPC, CANPC

Even when documentation requirements do not change, because we practice in an ever increasing regulatory environment, it is good to be reminded from time to time what is required for proper documentation. Let’s take a look at ultrasound guidance.

There are two different types of ultrasound guidance, one for needle placement, such as for acute and chronic pain blocks (76942) and one for vascular access, such as arterial lines and central lines (76937). Note that permanent images (that can be retrieved) are required to be saved for both ultrasound guidance codes.

CPT states the following:

Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process, either separately or within the report of the procedure for which the guidance is utilized.

Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable.

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Required documentation elements:

  • The evaluation of the anatomical site
  • The localization process
  • Obtain permanent images (note, the permanent image is not required to be in the documentation for this code; it has to take place but it doesn’t necessarily have to be put it in the dictation. However, it is highly recommended that you do include a note that states permanent images were saved in your documentation).

76937 – 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)

Documentation for this code differs from needle placement as all of the elements listed in the CPT descriptor (which have been underlined above) must be documented in order to report this code.

Required documentation elements:

  • Evaluation of anatomical site
  • Documentation of selected vessel patency
  • Documentation of real-time ultrasound guidance used for needle placement

By having precise, complete documentation you can rest assured that in the event of a payer audit of any type, your documentation will stand up to the toughest scrutiny.

Pam Linton, CPC, CANPC is a Corporate Coding Quality Specialist with Zotec Partners.