Saved Images Documented on Ultrasound Guided Procedures
These topics describe the Saved Images Documented on Ultrasound Guided Procedures alert.
Purpose
To help ensure that the storage of permanently recorded images is documented for ultrasound guided procedures.
Details
Storage of permanently recorded images must be documented for all ultrasound guided procedures. Failing to document the storage of permanent images in the patient’s record can lead to audits, down-coding, and/or non-reimbursements.
Modalities, exams, body structures, and sections
The NLP reasons over specific modalities, exams, and/or report sections. A summary of the inclusions for the "Saved images documented on an US guided procedure" exam are provided below.
Included | |
|---|---|
Modalities | Any |
Exams | Exams with ultrasound guidance (Ultrasound guided procedure examples: ablation, biopsy, aspiration, injection, drainage and localization) |
Report sections | All |
CPT Codes
The following is a list of CPT codes for procedures to which this Coding Compliance applies. This list is taken from the CPT reference material.
76932-76965
Examples for testing
The following examples are provided to help you test the alerts in FFI Assist. The dictation phrases are for demonstration purposes only and may not be clinically accurate. 
There is still a question regarding the need for the word "permanent" RADCT-279.
Exam type | Report section | Dictation phrase (satisfying verbiage bolded in examples) | Expected Assist alert | |
|---|---|---|---|---|
US Paracentesis with Image Guidance | FINDINGS | The skin was prepped and draped in usual manner. Local anesthesia with Lidocaine was administered and a right -sided paracentesis was performed. A 5 French One- Step paracentesis needle/catheter was then placed where marked. Approximately 11.5 L of clear yellow fluid was removed. The needle/catheter was then withdrawn. | Yes, because there is no documentation of saved images. | "US guidance exams require documentation of permanent images" |
US Renal Biopsy | FINDINGS | The patient was positioned prone on the ultrasound table. Limited sonographic images of the left kidney were obtained for the purpose of needle guidance. These demonstrate a large complex left inferior pole cyst measuring 6 x 7 x 5 cm. The left back was then prepped and draped in the usual sterile fashion. The skin and subcutaneous tissues were then anesthetized with 1% lidocaine. A small cutaneous incision was made to allow for passage of a 17 gauge coaxial needle. Next, under direct sonographic guidance, the needle was advanced into the complex cyst. Once positioned appropriately, the inner stylet was removed and a two cm 18 gauge core biopsy sample was obtained. Sonographic images of the pass was saved. Permanent images were stored in PACS. | No alert should fire | |
Interventional Radiology US-guided central line placement | FINDINGS | Real-time sterile ultrasound was used as a guide to assess the right internal jugular vein, which was found to be patent. Real-time sterile ultrasound was used to puncture the vein using micropuncture technique. Over a 0.035 wire, dilation was performed and a 15 cm triple-lumen catheter was placed, tip at the superior vena cava. Venous blood aspirated and injected easily through all three ports. The line was secured with suture. | "US guidance exams require documentation of permanent images" | |
Interventional Radiology US-guided vascular access | FINDINGS | Using real-time sterile ultrasound guidance, access was gained to the right internal jugular vein using single wall micropuncture technique. A permanent recording of the ultrasound image of the needle puncture of the internal jugular vein was obtained and archived. A 0.035 J-tip guide wire was advanced into the superior vena cava. | No alert should fire |