11/26/13 – Documentation for Ultrasound Guidance, 76942

Question: What are the documentation requirements for use of ultrasound guidance?  Do we need to show medical necessity?


Answer: Follow these three tips in order to avoid documentation mishaps and also to show medical necessity:


1) Ensure the physician states why he used ultrasound. It is important that the doctor state that the injection was guided by the use of ultrasound and not just used to identify the anatomy.


2) Check that documentation supports medical necessity. You should expect auditors to ask “Why, on this patient, is it necessary to use ultrasound when you’ve been doing these injections forever without them?” For example, the physician might state, “Because the patient has osteoarthritis, I have elected to use ultrasound today to ensure proper placement of the needle.” Or, if the patient was morbidly obese, the clinician might use ultrasound to help guide the needle.


3) Include a captured image in the medical record. Documentation must include an image of the procedure. It can be a hard copy or a digital image, and must be in the patient’s permanent medical record.  A copy of the image is not required for billing, but is helpful to have in case the insurance company requests it.


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