Anesthesia Coding Alert

Question: The anesthesiologist placed a line and used ultrasound guidance during the procedure. What documentation do we need to support the charge?

New Mexico Subscriber

Answer: According to the 2011 Relative Value Guide (RVG), the physician must include documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, and permanent recording and report.

Select the guidance code based on the physician's service. For needle placement, report 76942 (Ultrasound guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation For vascular access, turn to +76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting [List separately in addition to code for primary procedure]).

Regarding documentation, you need to maintain permanent images on file and have a separate, written report for either code to provide if the information is requested.