cpt 76882 billed with 59 modifier

glomaxie

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We are a rheumatology practice and have just recently encounter issues with Optima Health and Coventry no longer accepting 76882, billed with 59 modifier---in addition to any of the arthrocentesis codes with ultrasound. In other words: 20604, 20606 and 20611. They continue to insist that 76882 is inclusive with those codes, and even with documentation, they will not pay it. Medicare does allow us to bill this way and they pay us!! And yet both Optima Health and Coventry presumably follow Medicare guidelines!! Has anyone else encountered this issue? None of this was occurring in 2015. Thanks!
 

CodingKing

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Even if payers typically follow Medicare there is nothing stopping them from creating custom edits. It sounds as if these 2 payers decided they want to bundle the imaging, I mean the CPT description for the procedures does say "with ultrasound guidance, with permanent recording and reporting". If its typical to perform imaging with every procedure, they will bundle it in. NCCI does have an edit for these codes as well. So you may actually be reporting the modifier 59 inappropriately to Medicare.


The following was added to the NCCI manual Eff 1/1/16

If the code descriptor for a HCPCS/CPT code, CPT Manual instruction for a code, or CMS instruction for a code indicates that the procedure includes radiologic guidance, a physician should not separately report a HCPCS/CPT code for radiologic guidance including, but not limited to, fluoroscopy, ultrasound, computed tomography, or magnetic resonance imaging codes. If the physician performs an additional procedure on the same date of service for which a radiologic guidance or imaging code may be separately reported, the radiologic guidance or imaging code appropriate for that additional procedure may be reported separately with an NCCI-associated modifier if appropriate.

Remember Modifier 59 is very powerful, merely adding it to the claim will bypass edits even if its not supposed to be separately reimbursable. I'm thinking these payers have had too many inappropriate billings they changed it from a (1) eligible for NCCI modifier to a (0) modifier will not bypass.
 

glomaxie

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I do understand that a carrier can create custom edits--which is most likely what has now happened. But 76882 is not part of the "ultrasound guidance" for the needle placement. It is a totally separate "examination of an extremity that would be performed primarily for evaluation of muscles, tendons, joints, and/or soft tissues."

Our physicians also clearly document within the body of notes for the arthrocentesis procedures that they are doing this separate exam-(76882)--it has its own specific notes. I am thinking perhaps the only way to get it paid is for the notes to be completely drawn out form the arthrocentesis, and entered under it's own template in the emr. Then we can furnish documentation to support our billing.

I show under the NCCI edits, when billing the arthrocentesis codes with 76882, it does show it as (1)--eligible for modifier---but they do go on to show it also as "misuse of column two code with column one code"
 
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