07/25/2014 – Documentation for Ultrasound Guidance

Question: What are the documentation requirements for billing ultrasound guidance, code 76942?

 

Answer:  A final, written report should be included in the patient’s medical record which should contain:

 

– A permanent recorded image of the site being localized
– A 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.


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