Ask Dr. Z

The NCCI Policy Manual states that it is occasionally necessary to perform an epi-aortic ultrasound during a CABG and that you may report CPT 76998 when this procedure is performed. Does the physician have to document something specific to support the medical necessity of coding 76998? I have some physicians that simply state in their operative reports: "epi-aortic ultrasound performed; no abnormalities found." However, I thought the physician needed to document something more regarding the medical necessity [e.g., confirming the patient has extensive arteriosclerosis or a porcelain aorta and it is necessary to perform the epi-aortic ultrasound to find a safe spot to place bypass cannulae, a crossclamp, or a good target for the proximal anastomosis for the bypass graft(s)]. I can't put my finger on any specific authoritative guidelines to support that though. I would appreciate your thoughts on this topic.