Wiki 93970 upper and lower extremities

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chembree

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We have always billed 93970, 93970-59 when complete bilateral upper and lower extremity duplex ultrasounds are performed… but Medicare is stating this is incorrect billing for these procedures. Can someone offer any information on the correct billing of these exams?

We have also tried to use a 76 modifier but it was denied as well.
 
I, in the past did not bill 93970, 93970 59 for bilateral upper and lower extremity, Medicare considers 93970 bilateral body, so whether it is upper and lower bilateral it is still 93970. We would get paid with some of the other commercial payers by billing with a 59 on the second procedure, but never Medicare.
 
Our denial code CO-16 /M80- claims lacks info for adjudication and not covered when performed during the same session as a prev procedure.

Medicare also sent us a letter that says,
“In an effort to reduce possible billing issues for your office, Cahaba GBA is providing the enclosed information that provides billing instruction and includes a website explaining the proper billing of bilateral procedures codes. The enclosed document is also available on Cahaba GBA's website at the following address:
https://www.cahabagba.com/part_b/claims/fee_schedules/20122_fee_schedules.htm

An example of a procedure code that your office is billing incorrectly is 93970 26 59 (procedure code was billed on two lines for the same date of service and re-billed with modifier 76.) If your office bills for additional bilateral procedure codes, please review the correct billing method to avoid incorrect billing.”

I don't see any information that explains why you can't bill an upper and a lower exam together. It is almost as if they think we are trying to bill 93970 as a left and right exam vs. upper and lower. We have received many denials for these and have tried to appeal with reports and like I said we even tried using a 76 modifier instead of a 59.
 
It is almost as if they think we are trying to bill 93970 as a left and right exam vs. upper and lower.
Click to expand...

That's exactly what they think.
2 options - one is always add narrative of "upper" for one and "lower" for the other, but even this does not always help. Second is appeal - and don't stop at the first level - you may have to go at least 3 (you can do several at at time). AMA CPT Assistant, January 2012 and ACR Coding Source, Jan/Feb 2007 both address this and should be used for appeals.

Having said that, this should really be a fairly rare occurence, you would have to have medical necessity for both upper and lower extremities.

Medicare gets away with things like this because practices don't appeal, or only go the first level of appeal.
 
donnajrichmond said:
That's exactly what they think.
2 options - one is always add narrative of "upper" for one and "lower" for the other, but even this does not always help. Second is appeal - and don't stop at the first level - you may have to go at least 3 (you can do several at at time). AMA CPT Assistant, January 2012 and ACR Coding Source, Jan/Feb 2007 both address this and should be used for appeals.

Having said that, this should really be a fairly rare occurence, you would have to have medical necessity for both upper and lower extremities.

Medicare gets away with things like this because practices don't appeal, or only go the first level of appeal.
Click to expand...

Thank you. We have a large practice and don't do a lot of these but the ones we are doing are being denied. I am going to see if I can get a copy of the AMA CPT Assistant, January 2012. In some of the reports one doctor will do the lower and another doctor do the upper.... seems like those would be obviously separately reimbursed… but even those are denying even after us appealing them.
 
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