documentation requirements for ultrasound guided injections

I am looking for resources to show what documentation requirements are needed to bill for ultrasound guided injections.  there is a disagreement in our office as to whether a SEPARATE, STAND ALONE NOTE needs to be documented in order to bill a 20611 (for example).  My understanding was they did not need a separate note and could dictate what was done within the office visit note as long as it stated it was a ultrasound guided injection and where the injection was done. How is this documented in your practices?  thanks for your input!


  • The following was published by Karen Zupko:

    CPT Code 20610 or 20611?


    November 1, 2018

    Our physician performed a shoulder joint injection with ultrasound guidance.  The physician’s procedure note does not fully detail the ultrasound guidance, other than the ultrasound was used to do the injection. The physician does not document that images were saved (and we can’t find images).  The physician also does not have a separate report for the interpretation.  I am thinking we should report 20610 (large joint injection without ultrasound guidance) versus 20611 (large joint injection with ultrasound guidance).   Do you agree with my choice?

    Yes, the AMA published specific documentation requirements for the ultrasound-guided joint injections (20604, 20605 and 20611) when the codes were introduced in 2015.   In the absence of such documentation, the correct code is 20610.

    CPT code 20611 requires the following:

    • Documentation of a focused ultrasound evaluation.
    • Obtain, label, and interpret images in multiple planes through the specific area of concern.
    • Documentation of the normal anatomic structure and any pathologic findings.
    • Documentation of separate stand-alone report for the patient’s chart (CPT code and radiology requirement).
    • Documentation the procedure itself, including prep, intraservice work, and patient tolerance.
    • Documentation of the specific medication and dosage if a therapeutic injection was performed.

    *This response is based on the best information available as of 11/01/18.

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