# Pain Injections with U/S



## ortho1991 (Jun 3, 2014)

We have a discussion going on in the office re documentation for injections and U/S. Doc wants to bill 20552 with 76882 and 76942 here is the procedure note he will dic.

Biceps Tendon USG Injection 

?	Using ultrasound the biceps tendon groove at the proximal anterior aspect of the humeral head between the medial and lateral tuberosities was identified. The space below the transverse humeral ligament adjacent to the biceps tendon was then identified as the target using ultrasound
?	This site was also identified as the point of maximal tenderness by the patient
?	An image of the anatomy was recorded and saved to the patient?s record
?	The skin and subcutaneous tissue towards the target was anesthetized with lidocaine using a 25ga needle
?	Through the anesthetized tissue a 25 ga needle was advanced to the target using direct ultrasound guidance
?	Once positioned properly 1cc of 40mg Depomedrol and 1cc lidocaine was injected after negative aspiration
?	An image of the injection site was recorded and saved
?	The needle tract was flushed with lidocaine as the spinal needle was removed
?	No paresthesias were noted from the awake patient and the patient remained stable throughout the procedure
?	The patient was monitored for approximately ? hour before being discharged without weakness noted.

My biggest concern is the documentation for the 76882 is this enought to bill with.

Please any suggestions, or advise as to where we can find information will be appreciated.    Thank you


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## Michele Hannon (Jun 3, 2014)

CPT 76882 is considered use of ultrasound for a limited examination for the evaluation of soft tissue: a muscle tear, presence of a foreign body, tendon rupture or laceration or to determine the density of a cystic mass (this is not an all inclusive list). It would seem prudent to document your ultrasound exam findings.

You might also want to query your provider to help you understand the target muscle(s) he/she is injecting if using 20552. He/she reports a biceps tendon injection which would be 20550.


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## dwaldman (Jun 3, 2014)

With the note provided there is no diagnosis statement to support 76882. Was the structure normal without pathology to correlate with the patient pain in that area. The only describes location where the procedure takes place but does not have any diagnostic value to support 76882.

Below is a clinical example from AMA CPT Changes 2011 where the patient describes a specific structure that is causing pain and the patient receive an ultrasound evaluation to determine if pathology can be found or if the study is normal. Or if further studies should be carried such as MRI if it is unable to determine.

Clinical Example (76882)

A 36-year-old male presents with an acute injury to his Achilles tendon, sustained while playing soccer. No open wounds are noted. X-rays are negative for osseous pathology. Mild erythema and edema are noted at the posterior lower leg. Ultrasound is performed to evaluate the Achilles tendon.

Description of Procedure (76882)

Focused ultrasound evaluation of a specific structure; images are obtained in multiple planes through the specific area of concern, ie, Achilles tendon. Documentation of the normal anatomic structure and any pathologic findings are made. A report is dictated for the patient's chart.


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## dwaldman (Jun 3, 2014)

What needs to be provided is a clear separation from the ultrasound guidance with the performance of the procedure.

Then a separate report or section that describes what structures were examined for the diagnostic portion with a final impression or diagnostic statement to support the necessity of the examination and support that there was further aide in diagnosis by this examination.

Below is from the CMS NCCI Policy manual that should also be reviewed. In order to make sure the limitations are known for Medicare beneficiaries. 

" Ultrasound guidance and diagnostic ultrasound (echography) procedures may be reported separately only if each service is distinct and separate.  If a diagnostic ultrasound study identifies a previously unknown abnormality that requires a therapeutic procedure with ultrasound guidance at the same patient encounter, both the diagnostic ultrasound and ultrasound guidance procedure codes may be reported separately.  However, a previously unknown abnormality identified during ultrasound guidance for a procedure should not be reported separately as a diagnostic ultrasound procedure."


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## ortho1991 (Jun 5, 2014)

Your explanation makes it clear what needs to be documented, and when we should bill the two codes together.

Thank you both very much for taking the time to respond.


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