Ultrasound Guidance – Requirements for Compliant Billing

Published on October 4, 2017

Ultrasound Guidance – Requirements for Compliant Billing

Documentation requirements are often overlooked by anesthesia professionals when providing ultrasound guidance for an injection or catheter placement.  However, this can cause a big problem during the billing and collection process.  The AMA’s CPT Guidelines state the following in regards to Ultrasound Guidance:

“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.”

The permanent image recording as well as the written report are an integral part of this service.  Without them, you cannot bill it. 

Written report should include a description of the localization process.  This description can be written as a progress note, or included in the injection or catheter placement note, and should include the following: 

• Evaluation of potential access sites
• Selected vessel patency
• Real-time ultrasound visualization of vascular needle entry
• Documentation that a permanent recording has been archived in the medical record. 

In addition to the proper written documentation, a permanent recording of the guidance process along with images must be stored in the medical records, and must be accessible.  If you are unsure, whether this is being done, you should check with your hospital Radiology Department as well as Health Information Management Department. 

Many payers are now requiring copies of images and reports on claim review.  The lack of proper documentation is not only a compliance risk, but will also cost you money in denials or recoupments.   

The best way to avoid this risk and be reimbursed for your services is to verify that images are recorded permanently and document the service in a note every time.

 

By: Heather E. Golfos, CPC, CANPC

Coding Department Manager