Wiki is codumentation ok for that code?? 76937

[kviolet]

Can I bill 76937 for this note? Is documentation ok for that code Thanks!!!Procedure: intravenous line placement with ultrasound guidance
Indication: difficult access, multiple failed attempts by RN
22 gauge 1.5 inch needle placed under sonographic guidance in left antecubital fossa
good blood return, flushed easily with normal saline- no resistance. Secured with tape.

 

[mitchellde]

If that is all that is documented then you do not have enough to support the use of the 76937.

 

[kviolet]

yes, that is all, so where can I find supported documentation ?
Thanks
Wioletta

 

[mitchellde]

Look at the description of the code. You do not have any of the required components documented.

 

[kviolet]

where would you recommend ? Thanks!

 

[mitchellde]

The code description is in the CPT book.

 

[Chlrtrep]

This has been a widely talked about cpt code in regards to the documentation required to code for it. Using the description in the CPT code book we discussed with our physicians the criteria of the documentation this code requires. After that meeting this is how it is documented in the op reports now.


?ULTRASOUND EVALUATION OF THE RIGHT INTERNAL JUGULAR VEIN: Concurrent
real-time ultrasound imaging was utilized to evaluate the access site as
well as for direct visualization of the needle entry into the
vasculature. This was documented with permanent recording and reporting.
The right internal jugular vein was widely patent.?



I believe the keys things needed are visualization of the needle entering the vessel and patency of vessel and documentation the at permanent image has been stored in patients chart.

Code description:


CPT Code: 76937:

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, requires documentation of: selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting

 

[jbug94]

Chlrtrep, Thank you for explaining that so well. Sometimes production timed coders do not need to spend 20 or more minutes researching, hunting and reading articles about a new or out of the ordinary procedure. I frequently ask for fast help from senior coders, and then I can double check the terminology and documentation from the manuals. I'm a coder that needs help deciphering sometimes. I am keeping this for reference as now I am coding radiology. Thanks again for your knowledge