eweber16
Contributor
Hello,
Per the CPT Book, documentation of US guidance for PICC placement must include the following:
1. Evaluation of the potential puncture sites
2. Patency of the entry vein
3. Real-time ultrasound visualization of the needle entry into the vein
However, CPT Assistant states that the following should be documented when US guidance is done:
1. Evaluation of the potential puncture sites
2. Patency of the entry vein
3. Real-time ultrasound visualization of the needle entry into the vein
4. Image documentation (representative images from all modalities used are stored to patient's permanent record).
My questions are:
1. Do we need the actual Ultrasound images in our documentation to report 36573 (PICC line insertion w/imaging guidance)?
2. If images ARE needed, and they are NOT included in the patient's medical records, BUT, we do have all other documentation requirements met, do we report 36569 (PICC line insertion w/o imaging guidance), or can we still use 36573?
Thank you in advance for your input.
Per the CPT Book, documentation of US guidance for PICC placement must include the following:
1. Evaluation of the potential puncture sites
2. Patency of the entry vein
3. Real-time ultrasound visualization of the needle entry into the vein
However, CPT Assistant states that the following should be documented when US guidance is done:
1. Evaluation of the potential puncture sites
2. Patency of the entry vein
3. Real-time ultrasound visualization of the needle entry into the vein
4. Image documentation (representative images from all modalities used are stored to patient's permanent record).
My questions are:
1. Do we need the actual Ultrasound images in our documentation to report 36573 (PICC line insertion w/imaging guidance)?
2. If images ARE needed, and they are NOT included in the patient's medical records, BUT, we do have all other documentation requirements met, do we report 36569 (PICC line insertion w/o imaging guidance), or can we still use 36573?
Thank you in advance for your input.