BobLoblaw78

2+ Year Member
Jan 15, 2018
181
182
Status
  1. Attending Physician
We have concerns from our billing department regarding billing for ultrasound and fear of it being fraudulent without proper documentation. I have reassured them that it is standard to bill for ultrasound and our note more than adequate and it is in line with what a radiologist would dictate (actually it is better than some notes from radiologist..."needle overlying xxx area").

My standard note is:

"Sterile prep and drape of overlying region. 4" N-stim needle advanced under visualization utilizing ultrasound. XXX nerve, needle and vessel visualized under ultrasound. Local anesthetic as documented with complete/partial perineural spread. Negative heme throughout with multiple aspirations. Negative paresthesia (if true). Patient tolerated the procedure well with/without sedation and monitored throughout and afterwards."

Tell me if this is standard of care with your practice or if there is additional notation that you document in addition to saving the image. Also, do you save the image in the chart, print it off or save locally on USB/ultrasound machine?

Thanks in advance for the feedback!
 

SnapperRocks

5+ Year Member
Jun 9, 2015
409
539
Status
  1. Resident [Any Field]
If you did the block, used an ultrasound and stored an image somewhere, i think the worst that could happen is insurance asking for an image. If you can’t produce the image maybe they deny the claim. I am skeptical that poor documentation of something you actually did would be considered fraud.

If every block you’ve ever done you claim you stored an image and can’t produce one, then you may have an issue. I highly doubt every practice has 100% of images stored correctly or consistently.
 
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