January 31, 2019

Question:
When performing a carpal tunnel injection (20526) using ultrasound, what do I need to document to support reporting 76942?

Answer:
In order to report ultrasonic guidance using CPT code 76942 a permanent image of the ultrasound must be maintained.  It is recommended that you document the imaging guidance in a separate paragraph in the procedure note. Don’t forget medication (J code) can be reported separately for the injection.

*This response is based on the best information available as of 1/31/19.