EM with 20611- Is an additional report needed?

[jeburke23]

I have a provider that is considering the procedure section of their office note as support for the required "reporting" part of 20611. I cannot find any coding materials to support my claim that a separate report is needed.

 

[NRaizman]

Honestly it just depends on the detail in the procedure section. There is no requirement of a separate procedure note, but you will be likely to incur more audits and denials if the documentation is not clearly delineated from the E&M to support the separate and identifiable nature of the E&M relative to the injection.

 

[jeburke23]

It's not the support for the separate EM billing its the actual documentation requirements for the 20611 itself. Our CPT assistant states that "For 20611 Ultrasound Intraservice Work: Perform a focused ultrasound evaluation. Obtain, label and interpret images in multiple planes through the specific area of concern, focusing on best approach for injection. Document the normal anatomic structure and any pathologic findings. Utilize imaging to direct the needle to joint or burse, avoiding bony prominences, blood vessels, or other vulnerable structures. Dictate report for the patient's chart."

I also found the following which only further leads to me think that our provider needs to do additional documentation but I don't have access to AMA to verify.

"Question:
Our physician performed a shoulder joint injection with ultrasound guidance. The physician’s procedure note does not fully detail the ultrasound guidance, other than the ultrasound was used to do the injection. The physician does not document that images were saved (and we can’t find images). The physician also does not have a separate report for the interpretation. I am thinking we should report 20610 (large joint injection without ultrasound guidance) versus 20611 (large joint injection with ultrasound guidance). Do you agree with my choice?
Answer:
Yes, the AMA published specific documentation requirements for the ultrasound-guided joint injections (20604, 20605 and 20611) when the codes were introduced in 2015. In the absence of such documentation, the correct code is 20610.
CPT code 20611 requires the following:

• Documentation of a focused ultrasound evaluation.
• Obtain, label, and interpret images in multiple planes through the specific area of concern.
• Documentation of the normal anatomic structure and any pathologic findings.
• Documentation of separate stand-alone report for the patient’s chart (CPT code and radiology requirement).
• Documentation the procedure itself, including prep, intraservice work, and patient tolerance.
• Documentation of the specific medication and dosage if a therapeutic injection was performed.

*This response is based on the best information available as of 11/01/18."

 

[NRaizman]

But your question is whether there needs to be a separate report. The answer is that, as long as the requisite information is clearly included in the documentation, it can and should be submitted together. It helps if there is a subheading, just for clarity's sake in case of review or audit, but if the information is there, the information is there. Most EMR systems package it into the base note and that is industry standard and I have not encountered any issues with that practice.