I am currently using a MindRay DP50 machine. The problem I am having is that I use a 25 gauge needle for my injections and its hard to see the needle on the saved image. Is this a problem if I ever get audited from medicare? I dont want to have to use a larger needle. Anyone else with this issue?
Ultrasound
- Thread starter guptaa3
- Start date
- Joined
- Jul 26, 2010
- Messages
- 2,345
- Reaction score
- 191
Per medicare guidelines you do not to tchnicallys e teh needle saved on teh image. Just the structures/planes.....atleast at this time.
Agree with PinchandBurn. You currently do not need to see the needle on saved images. Almost any time you do an out of plane injection, you won't really see the needle very well anyway. Best thing to do is inject a very small amount at different intervals to see where your needle tip is at by seeing separation of myofascial planes or hyperechoic steroid.
- Joined
- Oct 7, 2011
- Messages
- 14,643
- Reaction score
- 5,944
if you the performer can identify where you think the needle is on the US, ive been told from a legal standpoint that that is sufficient.
i use a Sharpie to mark the path and the tip of the needle on my US images.
i use a Sharpie to mark the path and the tip of the needle on my US images.
- Joined
- Feb 2, 2008
- Messages
- 2,340
- Reaction score
- 796
I would respectfully suggest only using a 25G for superficial inj's or injections where you can get the needle quite parellel to the probe. For GHJ and Hip joint, use a 22G spinal, you will thank me 
. It will steer better and show up much better. I numb first with a 25G 2". Prob not news to you, but bevel facing probe also helps tip visual.
For knee and hip aspir on obese pts I use a 18G 5" Tuohy, works like a charm
. It will steer better and show up much better. I numb first with a 25G 2". Prob not news to you, but bevel facing probe also helps tip visual.For knee and hip aspir on obese pts I use a 18G 5" Tuohy, works like a charm
- Joined
- Jan 9, 2002
- Messages
- 6,517
- Reaction score
- 3,074
I use and like the 21ga 4" Pajunk echogenic needles when required (pudendals, suprascapular nerve, IA hips, etc). Very visible, but very expensive. Otherwise 25ga 1.5" or 22 3.5".
- Joined
- May 3, 2005
- Messages
- 4,238
- Reaction score
- 2,293
The reimbursement will soon go away for ultrasound and it will be bundled just as fluoroscopy has been. If you do a lot of procedures peripherally or have the skills to use US to diagnose (much more difficult than injections), then it is worth it. Of course anesthesiologists use US increasingly but they don't have to pay for the machine since the hospital buys it for them.
- Joined
- Mar 17, 2010
- Messages
- 13
- Reaction score
- 0
The reimbursement for this has already gone away for Medicare as noted below for First coast medicare. Someone already posted in june I believe , but this is what it spells out again.
Specifically for the 76942 code, they don't say that any documentation has to exists besides a pic. But it doesn't say anything specifically about labeling or interpreting anything (I still do as a "just in case"). They do list specifics for a "diagnostic ultrasound" but this a different code as below..
Minimum criteria for reimbursement of diagnostic ultrasound tests
First Coast Service Options Inc., (First Coast) recognizes that the miniaturization of electronic devices and advances in technology will lead to the increasing availability of certain real time images to clinicians. Such images may or may not be associated with improved test performance and added value to diagnostic/ therapeutic interventions. These evolving devices can range in complexity and capability from lightweight pocket-sized units completely contained within the examiner's hand to complex equipment systems where only the probe itself is hand-held.
The appropriate assignment of a specific ultrasound Current Procedural Terminology (CPT®) code(s) is not determined by the weight, size or portability of the equipment, but rather by the extent, quality and documentation of the procedure. While Medicare does not endorse any particular machine or device, professional organizations are available to address the functionality of particular machines and accredit laboratories that perform ultrasound studies. CPT® has guidelines addressing radiology coding and descriptors for procedures please see the 2013 CPT® book, radiology section, subsection, diagnostic ultrasounds page(s) 394-395. According to CPT® standards physicians and allied personnel are required to code to specificity and should only submit codes that are clearly separately reportable.
To be reimbursable by Medicare, a diagnostic ultrasound test must meet at least these minimum criteria (this is not an all-inclusive list):
It must be medically reasonable and necessary for the diagnosis or treatment of illness or injury.
It is expected that these services would be performed as indicated by current medical literature and/or current standards of practice.
It must be billed using the CPT® code that accurately describes the service performed including the intent of the code based on American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) established average intra service time and practice expense.
The technical quality of the exam must be in keeping with accepted national standards and not require a follow-up ultrasound examination to confirm the results.
The study must be done for an accepted clinical indication by a properly trained examiner and interpreted by qualified individuals within their scope of practice (weekend courses may not demonstrate expertise)
The medical necessity, images, findings, interpretation and report must be documented in the medical record.
An examination that does not meet the standards required for a complete diagnostic ultrasound examination will not be recognized as a valid diagnostic ultrasound service and will be non-covered.
Studies that do not meet these minimum criteria, regardless of the equipment used, should not be billed under diagnostic ultrasound codes or other CPT® codes. For example:
An emergency room quick look ultrasound to assess the chest for the presence of fluid, etc., may be useful as an extension of the physical examination. However, it does not meet the above standards and should not be coded as CPT® code 76604 (Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentation).
Interventional pain management procedures address a range of interventions, some with X-ray based imaging included in the procedure or separately coded when indicated. There are certain scenarios in which First Coast may or may not cover ultrasound imaging for CPT® code 76942 (Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device, imaging supervision and interpretation)) in the following clinical instances (this is not an all- inclusive list). For example:
An orthopedic surgeon, rheumatologist, or other physician/NPP performing a routine arthrocentesis of the knee for diagnosis and/or therapy (visco supplementation, corticosteroid injection) does not meet the guidelines for this procedure code.[/B][/B] Also, LCD 29307 -- Viscosupplementation Therapy for Knee, specifically non-covers ultrasound imaging for viscosupplementation.
Many episodes of care would not meet the intent of the code or meet the reasonable and necessary threshold for coverage (such as podiatrist or other provider treating Mortons neuroma, physician/NPP doing trigger point injections, nerve injections, physician/NPP treating symptomatic varicose veins, etc.)
Ultrasound guidance for needle placement may be payable when clinical circumstance warrants- such as a procedure where anatomy/organ evaluation is necessary; joint procedure where risk of osteomyelitis is significant; and the medical necessity of the service is clearly documented in the medical record (the unique patient has indications that are medically reasonable and necessary, and the images, findings, interpretation and report are separately documented in the medical record).
It is the expectation that physicians utilizing ultrasound guidance for standard office based needle procedures, either not code separately or bill the unlisted code (76999- unlisted ultrasound procedure (eg, diagnostic, interventional) with an appropriate fee.
CPT® code 76942 was weighted by the (RUC) to address physician work, practice expense & physician liability. The intra-service time of CPT® code 76942 is 30 minutes.
Of note, a large joint arthrocentesis is rated for five minutes of intra-service time.
Not all marginal improvements in the technical aspects of a procedure add complete value (are reasonable and necessary and/or are the established standard of care) nor are such improvements completely addressed in CPT® and the associated Medicare physician fee schedule.
CPT® codes 76881 (Ultrasound, extremity, nonvascular, real-time with image documentation; complete) and 76882 (Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific) describe an ultrasound imaging procedure for the evaluation of muscles, tendons, joints, and/or soft tissue structures generally after a standard radiograph does not determine the diagnosis and other imaging is not indicated (MRI etc.). Use of these procedures codes with aspiration and/or injection procedures would not be expected unless a separate musculoskeletal diagnostic evaluation is indicated and documented as reasonable and necessary.
Of note, CPT® codes 76881 and 76882 are generally paid if coded and billed correctly by qualified physicians and all other requirements of the Medicare program are satisfied though coverage (the medical record supports the medical necessity of the services). These two codes have 15 minutes intra service time and 11 minutes intra service time respectively unless a separate musculoskeletal diagnostic evaluation is indicated and documented as reasonable and necessary.
Per the Code of Federal Regulations (CFR) section 410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patients specific medical problem. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.
The provider is responsible for ensuring the medical necessity of the diagnostic radiology procedure(s) and maintaining the medical record, which must be available to First Coast Medicare upon request. Diagnostic radiology procedures, including ultrasound, are medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. It is also expected that ultrasound services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
WHEN EXPERIENCE COUNTS & QUALITY MATTERS
All contents © 2013 First Coast Service Options Inc. Disclaimer | Terms of use | Privacy Policy | About Us
Specifically for the 76942 code, they don't say that any documentation has to exists besides a pic. But it doesn't say anything specifically about labeling or interpreting anything (I still do as a "just in case"). They do list specifics for a "diagnostic ultrasound" but this a different code as below..
Minimum criteria for reimbursement of diagnostic ultrasound tests
First Coast Service Options Inc., (First Coast) recognizes that the miniaturization of electronic devices and advances in technology will lead to the increasing availability of certain real time images to clinicians. Such images may or may not be associated with improved test performance and added value to diagnostic/ therapeutic interventions. These evolving devices can range in complexity and capability from lightweight pocket-sized units completely contained within the examiner's hand to complex equipment systems where only the probe itself is hand-held.
The appropriate assignment of a specific ultrasound Current Procedural Terminology (CPT®) code(s) is not determined by the weight, size or portability of the equipment, but rather by the extent, quality and documentation of the procedure. While Medicare does not endorse any particular machine or device, professional organizations are available to address the functionality of particular machines and accredit laboratories that perform ultrasound studies. CPT® has guidelines addressing radiology coding and descriptors for procedures please see the 2013 CPT® book, radiology section, subsection, diagnostic ultrasounds page(s) 394-395. According to CPT® standards physicians and allied personnel are required to code to specificity and should only submit codes that are clearly separately reportable.
To be reimbursable by Medicare, a diagnostic ultrasound test must meet at least these minimum criteria (this is not an all-inclusive list):
It must be medically reasonable and necessary for the diagnosis or treatment of illness or injury.
It is expected that these services would be performed as indicated by current medical literature and/or current standards of practice.
It must be billed using the CPT® code that accurately describes the service performed including the intent of the code based on American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) established average intra service time and practice expense.
The technical quality of the exam must be in keeping with accepted national standards and not require a follow-up ultrasound examination to confirm the results.
The study must be done for an accepted clinical indication by a properly trained examiner and interpreted by qualified individuals within their scope of practice (weekend courses may not demonstrate expertise)
The medical necessity, images, findings, interpretation and report must be documented in the medical record.
An examination that does not meet the standards required for a complete diagnostic ultrasound examination will not be recognized as a valid diagnostic ultrasound service and will be non-covered.
Studies that do not meet these minimum criteria, regardless of the equipment used, should not be billed under diagnostic ultrasound codes or other CPT® codes. For example:
An emergency room quick look ultrasound to assess the chest for the presence of fluid, etc., may be useful as an extension of the physical examination. However, it does not meet the above standards and should not be coded as CPT® code 76604 (Ultrasound, chest, B-scan (includes mediastinum) and/or real time with image documentation).
Interventional pain management procedures address a range of interventions, some with X-ray based imaging included in the procedure or separately coded when indicated. There are certain scenarios in which First Coast may or may not cover ultrasound imaging for CPT® code 76942 (Ultrasound guidance for needle placement (eg, biopsy, aspiration, injection, localization device, imaging supervision and interpretation)) in the following clinical instances (this is not an all- inclusive list). For example:
An orthopedic surgeon, rheumatologist, or other physician/NPP performing a routine arthrocentesis of the knee for diagnosis and/or therapy (visco supplementation, corticosteroid injection) does not meet the guidelines for this procedure code.[/B][/B] Also, LCD 29307 -- Viscosupplementation Therapy for Knee, specifically non-covers ultrasound imaging for viscosupplementation.
Many episodes of care would not meet the intent of the code or meet the reasonable and necessary threshold for coverage (such as podiatrist or other provider treating Mortons neuroma, physician/NPP doing trigger point injections, nerve injections, physician/NPP treating symptomatic varicose veins, etc.)
Ultrasound guidance for needle placement may be payable when clinical circumstance warrants- such as a procedure where anatomy/organ evaluation is necessary; joint procedure where risk of osteomyelitis is significant; and the medical necessity of the service is clearly documented in the medical record (the unique patient has indications that are medically reasonable and necessary, and the images, findings, interpretation and report are separately documented in the medical record).
It is the expectation that physicians utilizing ultrasound guidance for standard office based needle procedures, either not code separately or bill the unlisted code (76999- unlisted ultrasound procedure (eg, diagnostic, interventional) with an appropriate fee.
CPT® code 76942 was weighted by the (RUC) to address physician work, practice expense & physician liability. The intra-service time of CPT® code 76942 is 30 minutes.
Of note, a large joint arthrocentesis is rated for five minutes of intra-service time.
Not all marginal improvements in the technical aspects of a procedure add complete value (are reasonable and necessary and/or are the established standard of care) nor are such improvements completely addressed in CPT® and the associated Medicare physician fee schedule.
CPT® codes 76881 (Ultrasound, extremity, nonvascular, real-time with image documentation; complete) and 76882 (Ultrasound, extremity, nonvascular, real-time with image documentation; limited, anatomic specific) describe an ultrasound imaging procedure for the evaluation of muscles, tendons, joints, and/or soft tissue structures generally after a standard radiograph does not determine the diagnosis and other imaging is not indicated (MRI etc.). Use of these procedures codes with aspiration and/or injection procedures would not be expected unless a separate musculoskeletal diagnostic evaluation is indicated and documented as reasonable and necessary.
Of note, CPT® codes 76881 and 76882 are generally paid if coded and billed correctly by qualified physicians and all other requirements of the Medicare program are satisfied though coverage (the medical record supports the medical necessity of the services). These two codes have 15 minutes intra service time and 11 minutes intra service time respectively unless a separate musculoskeletal diagnostic evaluation is indicated and documented as reasonable and necessary.
Per the Code of Federal Regulations (CFR) section 410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patients specific medical problem. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.
The provider is responsible for ensuring the medical necessity of the diagnostic radiology procedure(s) and maintaining the medical record, which must be available to First Coast Medicare upon request. Diagnostic radiology procedures, including ultrasound, are medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. It is also expected that ultrasound services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
WHEN EXPERIENCE COUNTS & QUALITY MATTERS
All contents © 2013 First Coast Service Options Inc. Disclaimer | Terms of use | Privacy Policy | About Us
- Joined
- Feb 15, 2011
- Messages
- 1,392
- Reaction score
- 840
It also notes that 76942 should take 30 minutes. So they try to cut it off from multiple directions, rather than just decrease reimbursement for it.
BCBS in the same region decided no 76942 for TPI, muscle or tendon injections. Agree with the TPI... however piriformis is also billed as a TPI. I was doing a significant amount of biceps tendon, medial/lateral epicondyle injections, piriformis injections and even caudals. They were all working really well but have been cut back a little bit unfortunately.
I would be very hesitant to purchase a brand new ultrasound machine. Strongly recommend a cheap used one if any at this point.
- Joined
- Jun 3, 2007
- Messages
- 4,694
- Reaction score
- 3,096
I think it is for patient care and perhaps saving yourself fluoro exposure over a lifetime - but I understand that is a contervesial point.
I have a hard time rapping my brain around this idea that imaging modalities are not going to be reimbursed. Again, I think patients need to start suing insurance companies.
Learning to understand spinal anatomy and as it pertains to xray takes time and expertise. Learning to drive a needle safely to certain spots takes time and training and expertise. Not only that, I believe it improve success rate.
Ultrasound has been shown to clearly improve success rate of placement in certain places in the body compared to blind. I think driving a needle under ultrasound, maintaining needle tip position and target all the time takes tremendous skill and practice. To even see the structures reliably with ultrasound takes many hours of practice. To everyone else that doesn't use ultrasound - no matter how great their anatomical skills are - it looks like snow to them, while to me I am seeing a C6 tubrelce, spinal nerve root, longis colli muscle and prevertebral fascia where I will place my local for an SGB.
It blows me away that insurance companies would rather us practice by placing needles blindly. ( I can only assume they want this since by denying payment to image guidance placement, they are unequivically saying it has NO VALUE.)
The answer is make them bleed with law suites. NO EXPERT in court would deny the value of image guidance.
Last edited:
- Joined
- Jun 3, 2007
- Messages
- 4,694
- Reaction score
- 3,096
1. Joints (glenohumeral, hip, SI, I have done knees but rather use fluoro)
2. Bursa (ie., subacromial, great trochanter, iliopsoas,etc)
3. peritendon (ie., biceps, hamstring origen, elbow shtuff, supraspinatus, etc)
4. trigger points (thoracic mid back pain, piriformis, anterior scalene for TOS, iliospoas with baclafen for spasticity, etc.)
5. peripheral nerves (ie., occipital, iliioinguinal, GFN, suprascapular, etc.) The other day I saw a guy with what I thought was developing CRPS from his carpel tunnel syndrome. He had developed dynamic allodynia along the lateral aspect of his upper and lower arm, with static allodynia in many other places about his hand and wrist. Under ultrasound, I did a mid forearm median nerve block with local to observe his response. He had complete resolution of all his allodynia and wrist pain. I then used the ultrasound to place steroid close to the median nerve under the flexor retinaculum.
6. Peripheral Stim placement. If you don't think it matters where those leads are placed (with relationship to scarpas and other facial layers) - try doing it with ultrasound and different depths and then come tell me it doesn't matter.
7. SGB
8. Cervical SNRB? I've done it a few times. I still prefer CT guidance with fluoro DSA.
Last edited:
