Accurate billing and documentation of ultrasound and fluoroscopic guidance require adherence to established guidelines. Whether the procedure is vascular or non-vascular, it is essential to use the correct codes and meet the specified documentation requirements.
Proper documentation includes an interpretation statement and image retention, that must be captured within the procedure note that describes the service rendered. Below is listing of key components of proper documentation.
- Evaluation of potential access sites
- Selected vessel patency
- Real-time ultrasound visualization of vascular needle entry
- Documentation that a permanent recording has been archived in the medical record.
| CPT Code | Description | Requires Interpretation Statement | Requires Mention of Image |
|---|---|---|---|
| 76942 | Used for non-vascular procedures involving ultrasound guidance, such as biopsies or injections. It ensures accurate needle placement and includes imaging supervision and interpretation. | YES | YES |
| 76937 | Applied for vascular access procedures, like catheter placements, where ultrasound guidance is used to evaluate potential access sites and guide needle entry in real-time. | YES | YES |
| 77002 | This code is for fluoroscopic guidance during non-vascular needle placement procedures. It provides real-time imaging to assist in accurate positioning. | YES | YES |
| 77003 | Used for fluoroscopic guidance in therapeutic injections or other interventions, ensuring precise delivery of treatment. | YES | YES |
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