Are you capturing ultrasonic guidance for your in-office procedures? The CPT® code description will indicate when these codes include this guidance, but there are instances where this work can be separately captured. For example, the following procedures don’t include ultrasound guidance:
Incision and Drainage Subcutaneous (10060, 10061)
Puncture Aspiration (10160)
Incision and Foreign Body Removal (10120, 10121)
Pericardiocentesis (33010)
Central Venous Catheter Insertion (36555, 36556)
Drainage of Tonsil or Peritonsillar Abscess (42700)
Aspiration of Bladder by Needle (51100)
Diagnostic Lumbar Puncture (62270)
Introduction/Injection of Anesthetic Agent aka Nerve Block or Digital Block (64400, 64405, 64408, 64420, 64421, 64425, 64430, 64435, 64449, 64450)
The description notes will provide guidance to point to the appropriate radiology codes to capture this work. Documentation of the interpretation and report can be included in the operative note, or as a separate note. Best practice for documentation would be to include:
Anatomic structures or landmarks viewed for the procedure
An assessment of what is visualized on ultrasound (e.g. any abnormalities)
Permanent storage of images
Contact the experts at The Rybar Group today, and we can assist you with all of your documentation and coding needs.
