Wiki 76942 & appropriate modifiers ?? HELP

[mchamberlain]

We bill for anesthesia providers, and have come across a pattern with the coding department, coding a -59 modifier with the 76942. Their reasoning is that the machine is owned by the anesthesia provider, and because they are billing "global" and using the -59. They also place a -59 modifier on the injection code itself.

Ex:
76942-59
64415-59

Does anyone have any input on whether or not there is an alternative modifier, or code (maybe no modifier needed at all?) Could this be dependent on the payor?

Just looking for other input on this. Thanks.

 

[MarcusM]

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf

The CPT Manual defines modifier 59 as follows:
“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”
Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.
1. Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

 

[dwaldman]

For billing Medicare or a carrier that follows similar rules, the global component for 76942 can not be billed in an hospital or ASC setting. They would only be able to report the professional component regardless of their ownership of the equipment. The only one that could bill the technical component in hospital or ASC setting would be the facility were the procedure took place.

 

[dwaldman]

I meant "where" the procedure took place. See below that again there is no global component billing in hospital or ASC setting from GE healthcare ultrasound reimbursement guide.

Modifiers Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to the use of ultrasound for breast procedures.

26 ? Professional Component A physician who performs the interpretation of an ultrasound exam in the hospital outpatient setting may submit a charge for the professional component of the ultrasound service using a modifier (-26) appended to the ultrasound code.

TC ? Technical Component This modifier would be used to bill for services by the owner of the equipment only to report the technical component of the service. This modifier is most commonly used if the service is performed in an Independent Diagnostic Testing Facility (IDTF).

Payment Methodologies for Ultrasound Services Medicare may reimburse for ultrasound services when the services are within the scope of the provider?s license and are deemed medically necessary. The following describes the various payment methods by site of service.

Site of Service

Physician Office Setting In the office setting, a physician who owns the ultrasound equipment and performs the service, or a sonographer who performs the service, may report the global code without a ?26 modifier.


Hospital Outpatient or an Ambulatory Surgery Center (ASC)
When the ultrasound is performed in the hospital outpatient or in an ASC, physicians may not submit a global charge to Medicare because the global charge includes both the professional and technical components of the service. If the procedure is performed in the hospital outpatient setting, the hospital may bill for the technical component of the ultrasound service as an outpatient service. The CPT code filed by the hospital will be assigned to a hospital outpatient system Ambulatory Payment Classification (APC) payment system, and payment will be based on the APC grouping. However, for Medicare, the hospital outpatient facility and the physician must report the same CPT code. If the physician is a hospital employee, the hospital may submit a charge for the global service.

Hospital Inpatient Setting
Although this service would not typically be performed in the inpatient hospital setting, if it is performed in this setting, charges for the ultrasound services occurring in the hospital inpatient setting would be considered part of the charges submitted for the inpatient stay and payment would be made under the Medicare MS-DRG payment system. However, the physician may still submit a bill for his/her professional services regardless.

 

[dwaldman]

Below from the CMS Internet only manual stating technical component will not be paid to physicians in the POS.

Medicare Claims Processing Manual Chapter 13 - Radiology Services and Other Diagnostic Procedures Table of Contents (Rev. 2915, 03-27-14)

20.2.1 - Hospital and Skilled Nursing Facility (SNF) Patients (Rev. 1782; Issued: 07-30-09; Effective Date: 07-01-09; Implementation Date: 07- 06-09)
Carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients. Payment for physicians? radiological services to the hospital, e.g., administrative or supervisory services, and for provider services needed to produce the radiology service, is made by the fiscal intermediary (FI)/AB MAC to the hospital as a provider service


Medicare Claims Processing Manual Chapter 14 - Ambulatory Surgical Centers


Contractors shall deny globally billed ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24) and use the following messages:
MSN 16.2 ? This service cannot be paid when provided in this location/facility.
N200 ? The professional component must be billed separately
Claim Adjustment Reason Code 4 ? The procedure code is inconsistent with the modifier used or a required modifier is missing. Note Refer to the 835 healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

 

[Mladen]

Is this service being performed in an office setting? Like a pain clinic run by an anesthesia provider? If so, you would not need any modifier attached to either code as they can be billed together...and the guidance could be billed as global since it's in the office setting and the provider owns the equipment. Modifier 59 is completely inappropriate in any setting though!