Cytopathology
Ultrasound guided fine needle aspiration (USFNA)
Documentation and billing in USFNA



Topic Completed: 1 March 2013

Revised: 3 January 2019, last major update March 2013

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PubMed Search: Documentation and billing USFNA

Related Topics: CPT coding, E/M codes

Joseph D. Jakowski, M.D.
Susan Meanor, R.T., R.D.M.S.
Page views in 2018: 212
Page views in 2019 to date: 90
Table of Contents
Definition / general
Cite this page: Jakowski J. D., Meanor S. Documentation and billing in USFNA. PathologyOutlines.com website. http://www.pathologyoutlines.com/topic/cytopathologyusfnadocumentation.html. Accessed October 18th, 2019.
Definition / general
  • Currently, neither practice accreditation nor personal certifications are required for reimbursement of USFNA procedures or for US examinations (except for noninvasive vascular US studies, which pathologists do not perform, as some states require certification for reimbursement)
  • To ensure proper documentation for reimbursement for an USFNA procedure or US exam, the practitioner must document these elements in the medical record:
    • Demographics including facility name, patient name, date and time of exam, etc.
    • Relevant patient clinical information
    • Medical necessity for the examination (including ICD-9 code)
    • Who performed the US examination
    • Scope of the examination (i.e. limited versus complete US exam):
      • Pathologist will almost always perform a limited US exam
      • Limited US exam: evaluation of a limited number of organs or limited portion of region evaluated
      • Complete US exam: one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region
    • US report with description of study, findings and impression, or limitations, etc.
    • US image retention with permanent storage and availability for future review
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