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ultrasound documentation requirement

Mike Posted Fri 03rd of February, 2017 13:39:34 PM
We billed for an ultrasound guidance for a biopsy. The carrier said it was not documented that we have the images documented on the dictation and will not pay the US. Are there guidelines on what needs to be noted on the report that the images are file?
SuperCoder Answered Mon 06th of February, 2017 02:24:02 AM

Hi,

According to CPT® section notes, the medical record should include

  1. Permanently recorded images of the localized site

  2. A description of the localization process.

CPT specifies that the ultrasound guidance documentation may be either separately recorded or located within the report of the procedure for which the guidance is utilized.

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