Even though coding guidelines stipulate that ALL diagnostic ultrasound examinations require permanently recorded images with measurements, (when such measurements are clinically indicated), ultrasound guidance for vascular access has additional requirements.  We have outlined these requirements in the attached information. 

1. ULTRASOUND GUIDANCE FOR VASCULAR ACCESS
Quick Look Summary:
• Documentation requirements for Ultrasound Guidance for Vascular Access
• Sample Documentation
The purpose of this information is to update and improve Interventional documentation when
ultrasound guidance is used to gain vascular access. In the next few weeks, HIS will be performing a very
concentrated audit of Interventional procedures that include an indication that ultrasound guidance is
being utilized. If you begin seeing reports come back to you through our send back process, please refer
to the guidelines below for improving your individual documentation.
CPT Code: 76937
CPT Description: Ultrasound guidance for vascular access requiring ultrasound evaluation of potential
access site, documentation of selected vessel patency, concurrent real-time ultrasound visualization
of vascular needle entry, with permanent record and reporting.
The actual description set forth by the AMA/CPT clearly lists the necessary documentation requirements
for reporting this code in addition to any vascular access procedures.
• Documentation must address the evaluation of potential access sites
• Documentation must address selected vessel patency
• Documentation must address the real-time ultrasound visualization of vascular needle entry
• Documentation must indicate the that a permanent recording has been archived into the PACs
system
In order to assign code 76937, the ultrasound equipment utilized must be able to capture hard copy
images and the radiology report must include documentation of permanent recording of the ultrasound
image(s).
Our resources go on to say that the use of handheld device to ease vascular access without
documentation of the criteria listed in the four bullets above is NOT reportable.
Recently, there have been articles published in our coding resources that state that there have been
times when the radiologist assumes that a permanent recording has been archived, only to find on an
audit that these images have not been saved. This has resulted in payment being recouped as well as
fines for incorrect billing. If the use of ultrasound intent is to locate a vein or mark a skin entry point for
a non-guided puncture, this would not meet the requirements for this code and cannot be separately
reported.
TGalan -1- Ultrasound Guidance for Vascular Access
HIS South – Radiology Division January 11, 2011

2. Sample Documentation:
“Ultrasound was used to image the right neck. The right internal jugular vein was shown to be patent. A
hard copy image was stored on PACs (or in patient record) documenting this service. Using real-time
ultrasound guidance, the needle was placed into the right internal jugular vein.”
Coding Resources Utilized for information: 2011 CPT Professional Edition, MedLearn Interventional
Radiology Coder, and CSI Navigator for Interventional Radiology/Procedures
TGalan -2- Ultrasound Guidance for Vascular Access
HIS South – Radiology Division January 11, 2011