Wiki joint injection with ultrasound

[574coding]

Hello,
Our provider has asked for a sample of an joint injection with ultrasound report-that meets the guidelines in the CPT book. Does anyone have one that they can share? He is not sure what all to enter in the report to support the ultrasound guided joint injection. Thank you

 

[574coding]

Joint injection with ultrasound

Right now all he has on the report is "knee injection under ultrasound guidance"

I do not feel this is enough. How is the text below? Do you think this is enough to support the ultrasound?

The patient was placed in the prone position on the treatment table. The skin over and surrounding the treatment area was cleaned with Betadine. The area was covered with sterile drapes, leaving a small window opening for needle placement. Ultrasound was used to identify the boney landmarks of the hip and the planned needle approach. The femoral artery was located by palpation of the pulse. The skin, subcutaneous tissue, and muscle within the planned needle approach were anesthetized with 1% Lidocaine. All injected medications were preservative free. With ultrasound, a *** spinal needle was gently guided into the ***. Multiple ultrasound views were used to ensure proper needle placement. Approximately *** nonionic contrast agent was injected under direct real-time fluoroscopic observation. Correct needle placement was confirmed by ultrasound. Finally, the treatment solution, consisting of ***. All injected medications were preservative free. Sterile technique was used throughout the procedure

 

[OCD_coder]

If I were auditing the documentation I would look for a separate paragraph for the ultrasound (mimicking a separate report) from the joint injection procedure note/paragraph. In that paragraph .the anatomical area would be documented as well as to the findings the provider saw on ultrasound before, during and after needle placement to complete the report required for 76942.

Otherwise, modifier TC should be appended only for use of the equipment.