per Encoder these 2 codes are not bundled. The report combines the findings into one but is clearly two approaches. The insurance I am having an issue with is Aetna. They are inconsistent however always bundle one into the other and only pay for one-sometimes the transvag and sometimes the pelvic ultrasound. When a 59 is appended to the bundled code(which goes against coding guidelines) the once-bundles/denied code is paid. I do not have this problem with any other carrier and get both codes paid first submission. Anyone else that can chime in or share their experience?
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Wiki 76830 and 76856
- Thread starter efuhrmann
- Start date
The pregnancy status of the patient and the purpose of the ultrasound examination determine the proper code.
• Transabdominal ultrasound:
• When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic codes should be used (76815).
• When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric codes should be used (76857) and if it is for complete use- 76856.
• Transvaginal ultrasound
• Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
• If the patient is pregnant use the code (76817).
• If the patient is NOT pregnant use the code (76830).
• It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.
• Transabdominal ultrasound:
• When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic codes should be used (76815).
• When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric codes should be used (76857) and if it is for complete use- 76856.
• Transvaginal ultrasound
• Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
• If the patient is pregnant use the code (76817).
• If the patient is NOT pregnant use the code (76830).
• It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.
I would like to give some info about COMPLETE and LIMITED, and the Modifiers US coding:
A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava.
Many emergency department ultrasounds are more focused than "complete.
" As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a "limited retroperitoneal ultrasound" (76775).
The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.
US Modifiers:
The most common modifier used with ultrasound is probably the -26 Professional Component modifier.
Ultrasound codes are combined, or "global," service codes that include both the technical component and the professional component. In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The professional component is reported by the physician for the interpretation of the ultrasound and documentation of the results.
There is nothing in CPT that prohibits the practitioner from also reporting the technical component (TC), if he/she provides all of the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed practitioners), even if the practitioners own the equipment, provide the supplies, and their personnel perform the technical service.
Also, modifiers -76 and -77 (repeat procedure or service) possibly used in the setting of repeat scans as patients deteriorate (eg, AAA), or planned serial exams (eg FAST).
A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava.
Many emergency department ultrasounds are more focused than "complete.
" As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a "limited retroperitoneal ultrasound" (76775).
The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.
US Modifiers:
The most common modifier used with ultrasound is probably the -26 Professional Component modifier.
Ultrasound codes are combined, or "global," service codes that include both the technical component and the professional component. In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The professional component is reported by the physician for the interpretation of the ultrasound and documentation of the results.
There is nothing in CPT that prohibits the practitioner from also reporting the technical component (TC), if he/she provides all of the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed practitioners), even if the practitioners own the equipment, provide the supplies, and their personnel perform the technical service.
Also, modifiers -76 and -77 (repeat procedure or service) possibly used in the setting of repeat scans as patients deteriorate (eg, AAA), or planned serial exams (eg FAST).
Corkey453
Contributor
76856 and 76830
Aetna considers these, when done together " a standard of care" without each having a different diagnosis showing medical necessity for each done at same session.
Has anyone had sucess appealing these denials?
Aetna Policy.
Susan Eosso, CPC,CPMA,CMRS
Aetna considers these, when done together " a standard of care" without each having a different diagnosis showing medical necessity for each done at same session.
Has anyone had sucess appealing these denials?
Aetna Policy.
Susan Eosso, CPC,CPMA,CMRS
dmkubida
Contributor
multiple ultrasounds- same day
I have just received a refund request from Group Resources (part of PHCS). they are bundling 76856 with 76830 and asking for monies back. Not real sure how to approach. The u/s are done for the same principal diagnosis so I can't use mod 59. Any advice?
I have just received a refund request from Group Resources (part of PHCS). they are bundling 76856 with 76830 and asking for monies back. Not real sure how to approach. The u/s are done for the same principal diagnosis so I can't use mod 59. Any advice?
bfontaine
Guest
Did you appeal the request for the refund and if so, what happened? We are having a problem with two different carriers (UHC and Coventry) denying these two codes as bundled and they never did before recently. Thanks
GaPeach77
Guru
Gather your clinical documentation and pursue with these payers who do not know the difference between a transvaginal or pelvic ultrasound. A few years back, I handled an appeal process with Aetna who requested a takeback on some procedures at an oncology practice. Needless to say with Aetna you will find that most likely the take back request was handled by a LPN or some type of nurse that may have coding experience but not in that field, therefore you really have a good chance of appealing this and winning with Aetna. I even included a a copied page out of the CPT book for their viewing and we won. Its clear as a crystal that these are two different procedures. Make sure your dx codes align with the reasoning to why the U/S is being done in both places. Good Luck and let me know how successful you are with this.
bfontaine
Guest
Thanks Simone! We will gather it all up and appeal like crazy!
IF 76817 AND 76856 COME IN SAME DOS WITH DIFFERNET ACCISSION BUT THE REPORT IS SAME THEN 76856 SHOULD BE NCINCL NO CHARGE INCULSIVE PROCEDURE
nielynco
Expert
Well first you would not bill 56817 (pregnant uterus TV ultrasound) with 76856 (non-pregnant uterus ultrasound) on the same date of service, especially as the pelvic ultrasound is normally done first with a full bladder followed up with the TV with an empty bladder. If your first ultrasound is not pregnancy related, the follow-up approach would also have to be non-pregnancy related). The AMA and the American College of Radiology have weighed in on correct coding when both approaches are reported (but using the combination of the codes that match for pregnancy or non-pregnancy) over the years. With respect to billing for both types of ultrasound, the American College of Radiology’s 2006 Ultrasound Coding User’s Guide says:
“The pelvic ultrasound using a full bladder as a window to the pelvis and a transvaginal ultrasound using a vaginal probe as a window to the pelvis are separately coded procedures. A common practice is for ultrasound departments to begin with a pelvic ultrasound performed through a full bladder and to supplement the examination with a transvaginal examination when necessary. Use 76856 or 76857, as appropriate, for the pelvic ultrasound procedure. Add 76830 for the transvaginal ultrasound. When the transvaginal examination is used as the only technique, use 76830 to code for the procedure.”
In the November 2023 CPT Assistant there is a Q&A about the ultrasound report when both approaches are used:
"When generating a combined report, the elements of each examination must be included and documented. To avoid confusion, inaccuracies, and errors, it is appropriate to have a single set of measurements instead of two separate sets of measurements (ie, one in the TA section and one in the TV section). By providing a unified set of the measurements obtained during the combined examination, clarity and consistency can be achieved." This Q&A also adds:
"Code 76856, Ultrasound, pelvic (nonobstetric), real time with image documentation, complete, may be reported if the intent was to perform a complete transabdominal ultrasound examination of the pelvis and the report includes an explanation of any missing or non visualized organ/structures. Conversely, if the intent was to perform a limited transabdominal examination, then it would be appropriate to report code 76857, Ultrasound, pelvic (nonobstetric), real time with image documentation, limited or follow-up. In addition, code 76830, Ultrasound, transvaginal, may be reported for the ultrasound examination."
So from a CPT and College of Radiology perspective both approaches may be billed separately and there is no requirement that a different diagnosis code be reported for each approach. Using this CPT information may help when you get a denial and appeal.