Anesthesiologists performing ultrasounds (US) to administer post-op pain blocks or place central lines must follow CPT documentation guidelines in order to bill for the service.
According to a December 2015 AAPC blog post, new instructions for 2016 CPT indicate that “a written report (e.g., handwritten or electronic) signed by the interpreting individual should be considered an integral part of a radiologic procedure or interpretation.” Additionally, in order for the procedure to be fully documented, AAPC recommends including the following elements in the procedure notes:
- Facility or location where the study was conducted
- Name of patient and medical records number
- Name of referring physician
- Type of examination/service
- Date of examination/service
- Time of examination/service
- Injection of dye
- Number of views
- Date of dictation
- Date and time of transcription
- Patient age or DOB
- Patient gender
- Clinical information and diagnosis code (if available)
- Procedures/materials
- Visualized anatomical structures normal/abnormal
- Findings
- Potential limitations
- Clinical issues
- Comparison studies and reports
- Impressions
In addition, in their Practice Parameter for Documentation of an Ultrasound Examination, the American Institute of Ultrasound in Medicine suggests “there should be a permanent record of the ultrasound examination and its interpretation. Images of all relevant areas defined in the particular parameter, both normal and abnormal, should be recorded in a retrievable format.”
For specific US procedures, anesthesiologists should document the following based on the CPT description of the procedure:
US Guidance for Central Lines (CPT® 76937)
- the use of US to evaluate potential access sites
- the use of US to select vessel patency
- the use of US to visualize vascular needle entry
US Guidance for Post Op Pain Blocks (CPT® 76942)
- the use of US to evaluate the anatomical region
- the use of US to place the needle
- the use of US to visualize the spread of the anesthetic agent
For more information, review the CPT® coding guidelines for these codes and ultrasounds in general. Also, download the American Institute of Ultrasound in Medicine’s Practice Parameter for Documentation of an Ultrasound Examination.
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