Ob-Gyn Coding Alert

Reader Question:


Question: A patient come in for an initial ob visit and, at that time, the doctor did a transvaginal ultrasound and diagnosed the fetus as having cystic hygroma. The doctor sent the patient to the ultrasound unit for a definitive diagnosis and to take a better look at the fetus. Later that day, the ultrasound unit called, stating that we could not bill for a transvaginal ultrasound because the insurance will not pay for two ultrasounds done on the same day, even if the ultrasound that they did (limited ultrasound) was different from the transvaginal we performed in our office. Is there a modifier we can use? How can we both bill for our services and get paid?

Christine Nieves
NYU Maternal Fetal Medicine, N.Y.

Answer: With the implementation of the Medicare Fee Schedule, it became increasingly important to ensure that uniform payment policies and procedures were followed by all carriers so when the same service is rendered in various carrier jurisdictions, it is paid for in the same way. Therefore, the National Correct Coding Council was contracted to develop correct coding methods to control improper coding that leads to inappropriately increased payments. They devised a manual for National Correct Coding Policy and Edits, which is divided into two sections: a) mutually exclusive procedures and b) comprehensive and component procedures.

Mutually exclusive procedures are those that cannot be performed during the same operative session. Comprehensive and compound procedures codes will not be reimbursed when the same provider renders the component procedure on the same date of service as the comprehensive procedure.

Because the transvaginal ultrasound and the limited ultrasound are neither mutually exclusive nor comprehensive and compound procedures according to the Correct Coding Initiative (CCI), there is no reason why you could not bill for the ultrasound you performed. Modifier -59 (distinct procedural service) would be appropriate to append to the transvaginal ultrasound code (76830, echography, transvaginal) to indicate that the procedure in not considered to be a component of another procedure, but is a distinct, independent procedure.

According to Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature, The issue as I see it is of a payer arbitrarily deciding a coverage policy which clearly has no basis in medical-necessity issues. I advise you to appeal the policy (after checking with the payer to be sure that the ultrasound unit had the facts straight) and then contact ACOG to complain about this payers policy. ACOG is now taking these types of issues head on and has a complaint form that an office can fill out and submit to ACOG about a problem with a payer.

The fact that the CCI does not bundle the procedures may be of little concern to this payer, so arguing this point might not be of much help. Modifier -59 is used when a procedure that is normally integral to another procedure is billed at (among other things) a separate patient session. This modifier might help, but only if the payer recognizes the modifier.