Art lines

[Random Anesthesiologist]

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I need some help with my art line placements. Specifically my radial art lines. Femoral, no problem, even on a blind stick. But for some reason I struggle with my radial placements. I know there is an old thread about this, but I was hoping for some more input. I usually have no problem hitting the radial artery, takes one, maybe 2 sticks sometimes. Threading is the issue. Sometimes I use those stupid Arrow kits, sometimes I use an angiocath. And I seem to lose it about 50% of the time.

So frustrating. I try to use ultrasound, not always available.

 

[urge]

You are probably hitting it on the sides.

 

[Hoya11]

I need some help with my art line placements. Specifically my radial art lines. Femoral, no problem, even on a blind stick. But for some reason I struggle with my radial placements. I know there is an old thread about this, but I was hoping for some more input. I usually have no problem hitting the radial artery, takes one, maybe 2 sticks sometimes. Threading is the issue. Sometimes I use those stupid Arrow kits, sometimes I use an angiocath. And I seem to lose it about 50% of the time.

So frustrating. I try to use ultrasound, not always available.

use the arrow kit. its easier than you think, dont overthink it/overanalyze it. tape the arm to the armboard, tape the thumb separately to the side of the amboard. prep. put your gloves on. feel for the pulse where it is strongest. give lido over this area, just a little on the skin, you dont want to hit the artery with the lido stick.

then insert the arrow kit at a 15-20 degree angle, shallow. advance slow towards your fingers that are feeling the pulse. if you have gone past your fingers and no flash, pull the needle back to the surface of the skin but not out, and redirect slightly more lateral or medial than where you did before. same shallow angle. do not re-enter and make another hole for no reason. you now just slowly make passes at or near the target area slowly until you get a flash.

you get a flash. is it filling up the aline kit? if so do A. is it just a quick little flash? if so do B. (if in doubt at all do B)
A. slowly advance the wire into the artery. then twist off (spin it in) the catheter over the wire into the artery.
B. transfixion method. just keep your same angle and advance the needle through the flash, through the artery, just blindly stick it a little deeper into the arm keeping your angle. then remove all other parts of the arrow kit and just leave the catheter in place in the SQ tissue. slowly pull the catheter back until it is shooting blood at you. once it is, insert the wire, thread catheter in.

 

[BobBarker]

As above. Additionally, on the arrow catheter there is a black band midway down. As you advance the wire, and approach a go past that band if you feel any "grit" at all you are not in. You can try to make micro adjustments with the catheter or go straight to option B at all. The wire advancing should be "like a hot knife through butter". There may be a touch of increased resistance but no grit. Ever.

Also, maintain palpation as you advance the needle with your offhand. I can feel if the artery goes right or left of my needle and adjust accordingly. This may prove more difficult for you as I have enhanced palpatory skills and briefly enter into a zen like state before embarking on such an endeavor. I enter the same state before jabbing my tuohy into a parturient with "sheet cake" back.

Finally, if struggling for too long just get the ultrasound and do it under live US. Some people have really calcified arteries and you have been jabbing the right spot but the target bounces off.

 

[jwk]

This may prove more difficult for you as I have enhanced palpatory skills and briefly enter into a zen like state before embarking on such an endeavor. I enter the same state before jabbing my tuohy into a parturient with "sheet cake" back.

Ah, but can you intubate a gravid fire ant?

 

[norwood]

As above. Additionally, on the arrow catheter there is a black band midway down.

Just to elaborate on that: the black band reflects the point where the wire is just starting to emerge from the needle/cannula combo.

Make sure the cannula isn't stuck on the needle before you start - occasionally they want to 'stick' and it makes it awkward to advance it gently. Just hold the part you'd normally hold to advance it, and give it a little twist clockwise/counterclockwise to make sure it moves freely.

As always, don't advance the cannula over the needle and then withdraw it back onto the needle - you risk shearing off the end and causing an embolus.

 

[BobBarker]

Ah, but can you intubate a gravid fire ant?

Getting there. I do now yield the Miller 2 as my light saber of choice.

 

[Mapleson D]

I'll repost the algorithm that I've developed over the years for a-lines:

Assuming use of the Arrow kit with the long tube.

1. Positioning. Put a rolled-up OR towel or a-line armboard under the wrist to extend it. I like wrapping tape around the pt's thumb and using that to extend the thumb (by running the tape strip under the OR table armboard or whatever the arm is on)

2. Prep

3. Palpate artery. It's often more medial than you think. Also, it's easier if you insert your line a bit more proximally than some people are tempted to. At (or just proximal to) the wrist crease, the artery is SO shallow that it's hard to get into. Easier where it's a little deeper.

4. Nick the skin with an 18g or other large needle. Keep the needle really flat and use it like a little scalpel; you don't want to get into the artery! I think the skin nick helps hugely with letting the catheter slide in without getting hung up.

5. Enter the artery at about a 30° angle. When you see a flash, lower the angle about as flat as it goes against the pt's thenar eminence.

6. If the blood is still crawling up the tube at the low angle, advance the wire. It should go in like butter. If you encounter any resistance, withdraw the wire and go to step 9.

7. If the blood flow stops when you lower the angle, raise the angle back up and adjust the position of the tip of your needle a little so that you get good blood flow when you flatten the angle. If you get good flow, advance the wire. If you can never manage to get good flow with the flat angle, go to step 9.

8. Twist the catheter to advance it into the artery. If you've made a skin nick and the wire went in with zero resistance, I've found that the catheter very nearly always slides in without a hitch.

9. If the initial wire pass met resistance, or you were never able to get good flow at the shallow angle, raise the angle back up and plunge that thing through-and-through. Remove the needle, grab a wad of 4x4s to catch the mess, slowly back out the catheter and use a separate wire once you get good pulsatile flow. If you get piddly continuous oozing flow, you can try the wire but it's pretty unlikely to be successful.

10. Practice, practice, practice, practice. The way to get good at anything is just to do it over and over and over. You'll develop a feel for it.


This method sounds complicated but really it's not. And I've found it to have a really high success rate.

 

[Planktonmd]

Oh dear God...
There is an artery... it has a lumen... just put the freaking thing in that lumen... and if you can't... just move on, no one ever dies because an A line was not placed!

 

[Random Anesthesiologist]

Oh dear God...
There is an artery... it has a lumen... just put the freaking thing in that lumen... and if you can't... just move on, no one ever dies because an A line was not placed!

I thought it was a pretty legit question. I'm asking for help. Why does that deserve snark?

For the other responses, I go in at about a 30 degree angle usually, get good return, sometimes difficulty advancing the wire, sometimes not. I wonder if I'm not sidewalling or actually using too steep of an angle. I'll try the various steps and see what works. I don't always have the luxury of asking someone to watch me for feedback, especially like this month when I'm alone on nights. We seem to have a lot of vasculopaths on 1+ pressors who can't get "accurate" cuff pressures even on distal extremities - 60/40 but bounding femoral pulses? Anyway, thanks for the tips.

 

[BuzzPhreed]

Become deft with the ultrasound. You will never go back. Everyone who watches you place one in less than 30 seconds - every time - will think you are a rockstar.

 

[Mapleson D]

I think your 30 degree angle is fine for entry, but try the technique of lowering the angle once you're in. That makes a very straight path for the wire, rather than it having to bounce off the back wall of the artery and turn a corner.

Try my algorithm above and just keep practicing. You'll get to the point where you can place an a-line in most patients in just a few seconds, and only have to trundle out the ultrasound on rare occasions.

 

[jope]

One tip I got that helped a lot was to use two fingers- the index and middle. Position the middle finger proximal and once you locate the pulse with both fingers, try to feel for both sides of the artery so you have a good virtual image of where to poke.

A second useful tip was to apply proximally-directed tension with your middle finger to tighten the skin a little

 

[Skip2myLou]

for me the trick with the arrow kits is going at the 20 degrees angle. a steeper angle gives you less margin of error and you usually end up past the artery by the time you see flash and your brain computes and tells your hands to stop.

 

[urge]

Become deft with the ultrasound. You will never go back. Everyone who watches you place one in less than 30 seconds - every time - will think you are a rockstar.

The ultrasound is very useful. However, my experience from watching trainees has been that people who use it all the time cannot put an a line by palpation. And vice versa, people who do palpation are not very good with ultrasound.

Nothing wrong with using the ultrasound but keep in mind that one you go that route you will become dependent on it.

I guess it is fine as long as you don't go on mission trips to Africa.

 

[Mman]

I thought it was a pretty legit question. I'm asking for help. Why does that deserve snark?

I'm not sure it was snark so much as actual advice. Biggest problem I see with newbies placing a-lines is they spend 5 minutes thinking about it and try to palpate exactly where the pulse is before getting started. Just do it. It's a safe procedure. Not much harm if you miss the artery. Get them positioned, maybe take a quick feel to see about where it is and then go for it. Advance smoothly down, if you see a flash get flow and get the catheter in. If you don't see a flash slowly back out and watch for flash on the way out in case you went quickly through on the way down. Then take a slightly different path left or right and try again. Repeat.


I never waste time palpaing (other than an initial feel to verify they actually have a pulse - usually in preop holding) ahead of time. Just clean them off, grab the catheter, and palpate a pulse as I'm doing it to fine tune my aim. No point in wasting time figuring out exactly where to break the skin open as you already know within about 5 mm one way or the other where it's going to be. There just isn't that much variation in the location of the radial artery in a wrist that is usually only about 3-4 inches wide.

Practice, practice, practice. Every now and then an a-line can humble even the most experienced of us.

 

[epidural man]

I disagree with the arrow kit comments. I doubt you will ever reach 99.9% profeciency (which is what you need) with that - maybe barely >90%. People trade cleanliness for an inferior technique in my opinion. Find another way to get good (through and through with a wire, advancing angiocath like an IV, etc).

Practice is the key of course. Get as many tips as you can from as many people you can (watch them, ask them, etc - not reading tips...not the same thing) and develop your own style. You will "feel right as rain in no time."

An ICU doc at my institution - soon to be at an Oregon institution - taught me to grab the dobbler thingy when you are having a tuff time finding the pulse. This works really great actually.

My palpation tip is this - try to put the pulse between your finger nail and tip of finger. That way, you know exactly where the maximal pulse is.

Second tip - be very maticulous in your probing. For example - if you make a pass and get nothing - decide if you are going to go medial or lateral - and march slowly in ONE direction. I see residents probe all over the place with no plan - doesn't work and drives me crazy.

 

[epidural man]

Oh, one more tip.

Make them hypercarbic (if tolerated) to help the blood pressure go up and stay up while placing the a-line. Alternatively, get the BP up chemically to help you. People tolerate hypertension very well - almost everyone tolerates transiet hypertension.

 

[epidural man]

Damn -

One more tip (which I rarely do but wish I had the balls to)

Two rock stars I worked with as a resident (that used angiocath through and through technique) always used 18g. They work SO WELL! I have done it a few times and each time, it is eazy breezy. If you do the pull back technique with a wire standing by, you know the tip of the catheter is well in the middle of the artery - you can't miss this! Blood squirts across the room - and the wire ALWAYS goes very easily.

The problem I see most often with the through and through with a 20g - pull catheter back - and wire technique...is people try and thread the wire WAY to soon - as soon as they see blood return in the catheter, they try to thread the wire. The blood should SQUIRT back - then the wire goes easy.

 

[Reciprocity79]

My palpation tip is this - try to put the pulse between your finger nail and tip of finger. That way, you know exactly where the maximal pulse is.

A thousand times this. We are always told to palpate the pulse with the tips of our fingers, but it wasn't until one of my attendings told me to palpate like this that I really felt like I could zero in on it. World of difference.

 

[BuzzPhreed]

The ultrasound is very useful. However, my experience from watching trainees has been that people who use it all the time cannot put an a line by palpation.

Rest assured I can still do it both ways.

You can see the radial artery with the ultrasound and see if it is calcified, small caliber, etc. You will struggle less with alines if you become good with U/S. You will look like a rockstar too when you plunk it in before your assistant routinely even has the pressure line set up. Putting it more distally will also mean it's more secure and less likely to dislodge.

 

[deleted9493]

Enter the vessel with the angiocath of your choice with bevel up. Once you have flow, STOP. Rotate the needle 180 degrees so that the bevel is down and advance the catheter off. Unlike a standard IV start, this method does not require you to advance the needle further after the initial flow. The distal tip of the needle--here rotated 180 degrees--acts as a guide to get the catheter beyond the anterior wall of the vessel. This works for IV starts, as well.

1. If it's not pulsatile flow, don't bother trying to wire. You'll do more harm than good.
2. Be slow with your needle passes. This will decrease the distance traveled between the times of "true vessel entry" and "observed flow"...decreasing the likelihood of back-walling the vessel and not knowing it.

 

[deleted171991]

One tip I would add is to first become 90+% proficient with the angiocath, so that you always have a backup plan while learning how to use the Arrow kit. Once you master ONE technique, you will gain a ton of confidence and will actually look forward to A-lines.

 

[Bostonredsox]

The ultrasound is very useful. However, my experience from watching trainees has been that people who use it all the time cannot put an a line by palpation. And vice versa, people who do palpation are not very good with ultrasound.

Nothing wrong with using the ultrasound but keep in mind that one you go that route you will become dependent on it.

I guess it is fine as long as you don't go on mission trips to Africa.

I used to think this way and shy'd away from using it. Now I realize I have no excess time to waste and this needs to be a 5 minute or less procedure in the unit.

If I can feel a strong pulse, I stick it.

If the pulse is weak or the pt is on multiple vasopressors, i use the US.

 

[periopdoc]

I disagree with the arrow kit comments. I doubt you will ever reach 99.9% profeciency (which is what you need) with that - maybe barely >90%.

Huh? I do all my a-lines with an Arrow. 100%. Average time to place is under five minutes. I time my a-lines due to billing.

Second tip - be very maticulous in your probing. For example - if you make a pass and get nothing - decide if you are going to go medial or lateral - and march slowly in ONE direction. I see residents probe all over the place with no plan - doesn't work and drives me crazy.

Couldn't agree more. Also agree with your later comment about increasing the BP this helps tremendously.

- pod

 

[BuzzPhreed]

Place the aline more distally in the wrist. Recleanse it with an antiseptic once more before you dress it. Keep the sterile dressing on it. Don't suture it. Don't futz with it. Pull it out as soon as it's no longer needed.

Problem solved.

 

[Random Anesthesiologist]

Hey, thanks for more input. I think the issue was with my angle. I placed one tonight that was like butter. This hospital I'm at this month doesn't have those Arrow kits, so I just used an angiocath with catheter over needle. It was pretty obvious what I was doing wrong before - too steep an angle and forcing the catheter into not the artery.

 

[Jay K]

Become deft with the ultrasound. You will never go back. Everyone who watches you place one in less than 30 seconds - every time - will think you are a rockstar.

Or think you're nuts and mock you incessantly…

Hasn't fazed me one bit, I use the u/s every time if it's available.
1) Identify the artery fast and whether it has pathology
2) Place the A-line anywhere on the extremity irrespective of easily palpable BP or not
3) Complete the procedure fast and accurately
4) Practice makes perfect
5) All that practice will pay off when you're called for that difficult A-line in the super morbidly obese, edematous patient on max pressors/vasoconstrictors sans A-line or CVL in the ICU.

 

[BuzzPhreed]

Or think you're nuts and mock you incessantly…

Haha, yeah that too.

 

[Random Anesthesiologist]

Or think you're nuts and mock you incessantly…

Hasn't fazed me one bit, I use the u/s every time if it's available.
1) Identify the artery fast and whether it has pathology
2) Place the A-line anywhere on the extremity irrespective of easily palpable BP or not
3) Complete the procedure fast and accurately
4) Practice makes perfect
5) All that practice will pay off when you're called for that difficult A-line in the super morbidly obese, edematous patient on max pressors/vasoconstrictors sans A-line or CVL in the ICU.

Yeah, u/s is such a great tool. Most of my lines (aline, cvl, vascaths) are in the ICUs anyway, so especially helpful when having to place a radial art line on someone on pressors or place central catheters, and with coagulopathic pts. Sometimes I don't have time to hunt for the u/s though.

I need to find some longer needles for access on the morbidly obese or super edematous patients.

 

[HollywdAnesth]

I don't think anyone should be given snark for art line tips. They are the most difficult line to get proficient at (in my opinion). Not to mention, many of the patients that require them are old, fat, and have vessels full of plaque.

I went through a progression to get as good as I am now.
1.First, go through and through. Use a regular 20 or 22 guage angiocath for this one. You'll also need a guidewire. Arrow makes wires for this specifically. Palpate, anesthetize. When you get a flash of blood, immediately go through the artery in the same trajectory as your stick. Remove the needle. Pull the catheter back slowly until you get pulsatile blood coming out of the catheter. Thread the wire through and you should be golden.
2. Once you get good at this, use an arrow catheter. The only difference is that you enter the vessel at a 30-45 degree angle. Once you get the flash, you drop the needle to parallel, while advancing ever so slightly to keep the tip of the needle in the vessel. Thread the wire as described above.
3. The next step is to use the arrow (or an angiocath) without the wire. It's the same as the 2nd progression, but you just thread the wire over the needle.

The biggest piece of advice I can give you is trouble shooting. If you get a flash with an arrow catheter but are unable to thread the wire, you can sometimes pull the wire back and then go through the backwall of the vessel with the needle. Thread the wire through the tip of the needle and attempt like method 1. I've had medium success with this, but it does give you a way to salvage a stick.
I agree with going more proximal in the wrist. The artery seems more straight there.
I bust out the ultrasound when I get a difficult one. My favorite way to use it is scan the artery lengthwise and watch the stick enter the vessel and the wire go through.

I've been using the vascular surgery 22 guage micropuncture kit for the really tough art lines. Once you get the needle in the vessel, you can just let go of it and grab your wire to use. I've had great success with this, though it does make a bit of a mess.

 

[Arch Guillotti]

I bust out the ultrasound when I get a difficult one. My favorite way to use it is scan the artery lengthwise and watch the stick enter the vessel and the wire go through.

Do you have an extra arm and hand? One to hold the probe, one to poke the vessel and another the thread the wire. is someone else threading the wire for you?

 

[HollywdAnesth]

Do you have an extra arm and hand? One to hold the probe, one to poke the vessel and another the thread the wire. is someone else threading the wire for you?

Good question. If the probe is small enough, you can put it in the web of your hand reaching your fingers across to steady the needle as you guide the wire through.
Usually, I just get the view I want, and then have an assistant hold the probe in place for me.

 

[BuzzPhreed]

Do you have an extra arm and hand? One to hold the probe, one to poke the vessel and another the thread the wire. is someone else threading the wire for you?

Arrow kit. Hold probe. Place needle into lumen. Watch blood flow into hub. Set probe down. Lower angle. Float wire in Arrow kit into lumen. Seldinger catheter over wire into lumen. Apply pressure proximally. Withdraw needle-wire. Connect to tubing.

Less than 30 seconds start to finish.

 

[BuzzPhreed]

Less than 30 seconds start to finish.

... and, two hands. No blood loss.

 

[deleted162650]

If it's a difficult art line that needs U/S, I use a 20g jelco/angiocath and go with an in-plane view. With a very shallow angle I can advance the angiocath until the catheter is well within the lumen, and then just thread the rest of the catheter. No wire needed.

 

[urge]

Arrow kit. Hold probe. Place needle into lumen. Watch blood flow into hub. Set probe down. Lower angle. Float wire in Arrow kit into lumen. Seldinger catheter over wire into lumen. Apply pressure proximally. Withdraw needle-wire. Connect to tubing.

Less than 30 seconds start to finish.

1 How is that different from no ultrasound?
2 You didn't count the time it took you to get the US ready, including walking around getting the machine, putting the name in, and putting the condom on?

 

[BuzzPhreed]

1 How is that different from no ultrasound?
2 You didn't count the time it took you to get the US ready, including walking around getting the machine, putting the name in, and putting the condom on?

I don't get the ultrasound. I tell someone I need it and it's there.

The difference is I can see where I'm putting the needle tip. Just the other day I tried one without it, got a flash, no thread. The ultrasound was called for, circulator got it, and I could immediately see a tiny caliber artery. One stick - aline done. Start to finish, less than five minutes. Better than the cardiac anesthesiologist I watch sometime taking twenty to do one the old fashioned way in the pre-op area.

 

[Bostonredsox]

Arrow kit. Hold probe. Place needle into lumen. Watch blood flow into hub. Set probe down. Lower angle. Float wire in Arrow kit into lumen. Seldinger catheter over wire into lumen. Apply pressure proximally. Withdraw needle-wire. Connect to tubing.

Less than 30 seconds start to finish.

This is how I do every single art line In MICU. Unless there pulse is bounding. Then I do this minus the probe.

 

[Bostonredsox]

1 How is that different from no ultrasound?
2 You didn't count the time it took you to get the US ready, including walking around getting the machine, putting the name in, and putting the condom on?

Our machine is I.n the unit, 40 feet away from a pts door. And I don't enter names. I press power as I'm walking to pts room, after about 15 sec, I stick the probe on the wrist and stick the artery. Done.

 

[Mman]

Arrow kit. Hold probe. Place needle into lumen. Watch blood flow into hub. Set probe down. Lower angle. Float wire in Arrow kit into lumen. Seldinger catheter over wire into lumen. Apply pressure proximally. Withdraw needle-wire. Connect to tubing.

Less than 30 seconds start to finish.

That's what I do if I'm called in to help someone else who is struggling or I can get it after a minute. But honestly while doing it that way is probably 30 seconds start to finish, that's about 20 seconds longer than the procedure needs to be > 90% of the time.

 

[Random Anesthesiologist]

Our machine is I.n the unit, 40 feet away from a pts door. And I don't enter names. I press power as I'm walking to pts room, after about 15 sec, I stick the probe on the wrist and stick the artery. Done.

I don't bother with patient ID stuff on the u/s either. One of the u/s machines would let me do that, the other doesn't.

 

[urge]

I hope for your sake that all of you who are not entering the patients name do not document that an ultrasound was used. Otherwise the billing company will bill for the ultrasound and eventually you will be accused of fraud when audit time comes and you have no pictures of said procedure.

I know a lot of you value looking slick over common sense, but, seriously it is a no brainer.
1 That minute you save per aline adds up over the years to a few million in fines.
2 Why not get the money if you are using it?

Plus, everybody knows you suck without it. So, chill out slick.

 

[Random Anesthesiologist]

I hope for your sake that all of you who are not entering the patients name do not document that an ultrasound was used. Otherwise the billing company will bill for the ultrasound and eventually you will be accused of fraud when audit time comes and you have no pictures of said procedure.

I know a lot of you value looking slick over common sense, but, seriously it is a no brainer.
1 That minute you save per aline adds up over the years to a few million in fines.
2 Why not get the money if you are using it?

Plus, everybody knows you suck without it. So, chill out slick.

I have used the ultrasound for some radial art lines and all femoral art lines. They have all been in the ICU with numerous witnesses and co-documentation by nursing. If the requirements for documentation are different when I start my anesthesiology training at a different institution, I will follow their rules. Until I'm told otherwise, I document if I did or didn't use u/s, and give my attending a facesheet.

 

[Libertas]

Residents don't bill for anything, or even touch any of the billing sheets, at least at any hospital I've been at! Thank God that is somebody else's job. We just take care of the patients 😛 And fill out >12 review of system elements, heh

 

[Bostonredsox]

I hope for your sake that all of you who are not entering the patients name do not document that an ultrasound was used. Otherwise the billing company will bill for the ultrasound and eventually you will be accused of fraud when audit time comes and you have no pictures of said procedure.

I know a lot of you value looking slick over common sense, but, seriously it is a no brainer.
1 That minute you save per aline adds up over the years to a few million in fines.
2 Why not get the money if you are using it?

Plus, everybody knows you suck without it. So, chill out slick.

I'm a resident I don't get paid for any procedure. And as a hospitalist at my shop I won't get paid for Them either. I do print the pictures out long and short axis for my CVC. I do not print pics or bill i used the machine for the Aline's.

 

[Ignatius J]

I hope for your sake that all of you who are not entering the patients name do not document that an ultrasound was used. Otherwise the billing company will bill for the ultrasound and eventually you will be accused of fraud when audit time comes and you have no pictures of said procedure.

I know a lot of you value looking slick over common sense, but, seriously it is a no brainer.
1 That minute you save per aline adds up over the years to a few million in fines.
2 Why not get the money if you are using it?

Plus, everybody knows you suck without it. So, chill out slick.

I think you're being overly demonstrative. Some u/s machines don't even have patient ID capabilities. I think a printout with a patient sticker or written MRN would suffice with billing companies.

 

[nimbus]

We never bill ultrasound guidance for Aline's. Do people actually get paid for this?

 

[urge]

We never bill ultrasound guidance for Aline's. Do people actually get paid for this?

1 extra unit. Not bad for putting a name in and taking a picture.

 

[urge]

I think you're being overly demonstrative. Some u/s machines don't even have patient ID capabilities. I think a printout with a patient sticker or written MRN would suffice with billing companies.

As long as it is in the medical record it is fine.

What you don't want is to have the billing company bill for it without having a picture in the record.