Anesthesia and Invasive Line Ultrasound: A Fresh Look at Billing and Documentation

Summary
Opportunities for billing ultrasound were expanded for anesthesia providers in 2019—specifically in connection with invasive line placement. This article seeks to provide helpful guidance on payment issues and documentation requirements.

We recently provided you information relative to ultrasonic guidance (USG) in connection with post-operative pain blocks, as reflected by CPT code 76942. As promised, we now turn to the topic of USG used in the placement of invasive lines. This service is captured by CPT 76937, the code descriptor of which states:

Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure)

In the sections below, we will provide detailed guidance on how to properly capture payment for this imaging service.

Expanding the View

It should be noted that, unlike CPT 76942, CPT 76937 is an add-on code—meaning that it must be billed in conjunction with another procedure code that is also listed on the same claim form. Historically, that has been a code reflecting the placement of a central line (CVP), typically CPT 36556. This was due to a bundling of USG into arterial lines (A-lines), CPT 36620, and pulmonary artery (PA), or Swan-Ganz, catheters, CPT 93503. As we noted in an earlier alert, the American Medical Association (AMA), through its parenthetical notes in the CPT coding manual, has unbundled USG from A-line and PA catheter placements, opening up a new revenue stream for anesthesia providers.

A Clearer Focus

Of course, it does no good to ratchet up your utilization of USG relative to these additional lines, and to bill for such services, if you do not provide the necessary documentation in the medical record to support their payment. Toward that end, and by way of reminder, when submitting a claim for CPT 76937, we require that you adhere to the following documentation protocols:

1. Document the invasive line for which USG was utilized.
2. Document the utilization of USG.
3. Ensure that the anesthesia record clearly indicates who performed the line/USG service. If billing support for the line/USG service is to be based on a medical record other than the anesthesia record, such as a procedure note, that document must be signed (first initial, full last name) and dated by the individual performing the line/USG.
4. According to an article in the CPT Assistant—the publication that the AMA uses to further clarify coding, utilization and documentation requirements—CPT 76937 requires a recorded image of the vascular access site. This image must be retained in the patient's record or within a medium that allows the image to be connected to the patient and retrieved when requested. Accordingly, we require the following:
   
   a. There must be an indication on the medical record that is provided to us for the purpose of billing USG (e.g., anesthesia record, op note) that the USG image was retained. Some groups have an embedded attestation statement to this effect with an adjacent check box.
   
   b. Alternatively, groups can send us, by way of email, an attestation that they consistently retain the USG image and that they are able to retrieve such image upon request. (In other words, the image is able be tied to the individual patient, whether in hard copy or electronic form.) If there are any exceptions to this, per location, we would need to have those specifics noted within the attestation. When there are updates to the attestation's parameters (e.g., location added, change in image retention capability), the group would need to provide those to us in a timely manner in the form of a supplemental attestation.

5. Since the CPT descriptor for this service, noted above, includes the word "evaluation," a medical note memorializing the evaluation's findings is expected. The descriptor also includes other documentation requirements (e.g., patency), while CPT's introductory section to the CPT "Radiology Guidelines" requires the performing clinician to provide a "description of imaging guidance in the procedure report." To capture all these elements, the provider may want to create a documentation template that includes language similar to the following example:

1) US was used to identify the ____ vessel. (2) It was assessed and patent. (3) US was used to visualize vascular needle entry into the ____ vessel.  (4) The selected vessel appeared anatomically normal and (5) there were no apparent abnormal findings. (6) A permanent ultrasound image was saved in the patient's record.

At the very least, the #3 element in the above example (in bold) must be indicated on the medical record that we receive for billing purposes (e.g., anesthesia record, procedure note).

We want to make sure you are fully and appropriately paid for all of your services, and we thank you for cooperating with us in providing the documentary support needed for USG claim submission. If you want to know if your use of USG for vascular access is consistent with these guidelines, or if you have any questions concerning this issue, please feel free to reach out to your ABC/Medac account executive.