Question Image documentation

[RABBIT2020]

Can you use only an image report to code for the surgical procedure cpt and the ultrasound cpt?
Can the ED doctor code the surgical procedure with the radiology cpt?
Two separate section cpt using only the ultrasound report!!!

There is no order for a surgery section cpt procedure in the E/M note.
There is not a notation in the E/M that a surgery section procedure nor a radiology section procedure will be performed.
The bedside radiology report is just present in the chart for the same date as when the patient was seen in the Emergency department.
The patient is in the Emergency department and medication are ordered to be administered by IV. The timeline shows that no IV line was placed in the ED department.
The patient is in an altered mental state.

Provide any guidelines to show that this is permissible.

 

[thomas7331]

36410 is a physician service code. It does not require an order (physicians don't have to write orders for services they personally perform), but it does require that a physician document having done the procedure. So I agree with you, that code can't be assigned without that documentation - you can't assume a physician did this simply because ultrasound guidance was used. And yes, the add-on code will reject if not billed with the appropriate base code.

If this chart had come to me while I was coding for the facility, I would have returned it with a query to the physician to add an amendment for documentation of the venipuncture, or otherwise offer clarification regarding performing vascular access guidance if a venipuncture was not performed. I wouldn't let it get under my skin though - 36410 involves about $10 in reimbursement to a provider and none to the facility. There are a lot bigger things at stake in healthcare these days than something like this. You have to choose your battles.

 

[thomas7331]

I’m afraid I’m not able to make sense out of your post here. You’ll need to provide more detail about what is actually documented and what codes you are considering. I don’t know what ‘surgery section CPT’ you’re referring to here or what your radiology report actually says, and without more information, it’s just impossible to even begin to answer. Accurate codes can only be derived from documentation, not from vague or hypothetical scenarios.

 

[sls314]

I do agree with Thomas that this is hard to answer or provide guidelines without more specific detail.

Surgical procedures should be documented. What was the ultrasound for? Was it ultrasound guidance for the procedure? What was the surgical procedure?

 

[RABBIT2020]

Patient is seen in the ED for altered mental state. The plan includes labs. Labs were ordered and obtained. There were absolutely no mention that the there was difficulty obtaining blood by the RN. The documentation does not in any way state that the doctor draw the blood. in the chart for the same date of service there is a an ultrasound guidance by one of the group doctor as documented below.
This is an add on service +76937
An explanation was given to me to use cpt 36410 for the lines highlighted in blue below. However, since no where on the record states blood was obtained; RN was unable to obtain blood and therefore require doctors presence; How many attempts were made; needle was flushed etc. I am afraid I am not convinced that I have anything to support that it was 36410 that was done and is the primary cpt.
It is quite possible the venipuncture by a physician was done but it is probable that it was not! I need to know if a procedure from the surgical procedure section is included in the ultrasound report. To me the ultrasound report in its entirety has met all the elements needed just for a radiology diagnostic report only.

Hope this explains and I can get some feedback. Thanks.


Vascular Access (ED)
Exam information: Exam Type: Diagnostic
Vascular Access: Central Venous Access, Peripheral Venous Access
Indication: Difficult Access
Procedure: Vessel: right, Peripheral Vein: Antecubital
Ultrasound Procedure: vessel located and patency assessed by: compression Procedural guidance: dynamic ultrasound guidance.
Confirmation: visualization of needle in vessel lumen functional catheter.
Impression: Successful ultrasound guided vascular access