Part B Insider (Multispecialty) Coding Alert

Published on Sat Apr 09, 2011 PDF

Question: Can we bill 76856 together with 93975 using modifier 59?

Answer: Yes, you may report the two codes together when documentation supports that choice. Correct Coding Initiative edits bundle 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) into 93975 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study). The edit's modifier indicator of 1 means that you may override the edit in appropriate cases. You should append modifier 59 (Distinct procedural service) to 76856 when documentation supports overriding the edit.

Before you consider reporting both codes, verify that your documentation meets CPT®'s requirement that the provider must perform both color and spectral Doppler to report a Doppler exam. In the Diagnostic Ultrasound guidelines, CPT® also states you may not report color Doppler performed simply for anatomic structure identification with a real-time ultrasound.

Best bet: The physician should dictate a separate paragraph for the duplex if she wants to bill it, including why both exams were necessary. You need enough information to justify appending modifier 59 on the US code. Otherwise the payer will bundle the US into the duplex.

For example, documentation may follow the below sample:

• Transabdominal imaging showed ...
• Color and spectral Doppler showed...

You also will need to verify whether documentation

supports reporting complete US code 76856. For example, CPT® requires a complete female nonobstetric pelvic US to include "the complete evaluation of the female pelvic anatomy. Elements of this examination include a description and measurements of the uterus and adnexal structures, measurement of the endometrium,measurement of the bladder (when applicable), and a description of any pelvic pathology (e.g., ovarian cysts, uterine leiomyomata, free pelvic fluid)."

If your physician does not include all of this information, you will be limited to 76857 (Ultrasound, pelvic [nonobstetric], real time with image documentation; limited or follow-up [e.g., for follicles]).