Question CO97 Denial for 93880, 76536

SHEENAJONES

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Brand New Coder here and I'm not even actually working in a coding capacity at the moment. I am in billing.
My employer presented me with the task of trying to resolve a CO97 for a Surgical Center that we bill for and was wondering if someone with more experience can give me some advice.

Claim was denied CO97 for CPT 93880 as inclusive. (2 other lines paid: 99213 + 76536). I was given the directive of this blog post (https://www.aapc.com/blog/43413-double-check-duplex-scan-documentation/)
There is a different DX on each line (93880 + 76536) which would support the theory presented in the blog post; indicating that duplex + ultrasound can be billed on dame day but need to be clinically indicated.

I've reviewed the EMR and notes; PT has bilateral carotid stenosis AND an asymptomatic thyroid nodule. The DOS 4-9-2019 of the denial was actually a 1-yr f/u. Future care plan includes PT returning in 2-yrs for thyroid + carotid duplex.
Does this support medical necessity? Or should I be looking for something else?

If it does support medical necessity, I believe we’ll need to do a claim payment inquiry with Humana since they denied with an appropriate modifier.
 
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Best answers
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Brand New Coder here and I'm not even actually working in a coding capacity at the moment. I am in billing.
My employer presented me with the task of trying to resolve a CO97 for a Surgical Center that we bill for and was wondering if someone with more experience can give me some advice.

Claim was denied CO97 for CPT 93880 as inclusive. (2 other lines paid: 99213 + 76536). I was given the directive of this blog post (https://www.aapc.com/blog/43413-double-check-duplex-scan-documentation/)
There is a different DX on each line (93880 + 76536) which would support the theory presented in the blog post; indicating that duplex + ultrasound can be billed on dame day but need to be clinically indicated.

I've reviewed the EMR and notes; PT has bilateral carotid stenosis AND an asymptomatic thyroid nodule. The DOS 4-9-2019 of the denial was actually a 1-yr f/u. Future care plan includes PT returning in 2-yrs for thyroid + carotid duplex.
Does this support medical necessity? Or should I be looking for something else?

If it does support medical necessity, I believe we’ll need to do a claim payment inquiry with Humana since they denied with an appropriate modifier.
According to FindAnyAnswer "93880 and 76536 are mutually exclusive, the one with higher RVU i.e 93880 should be billed with modifier 59"
 
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