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Help with Humana 76881 denials

Jpad

Networker
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My company recently received both refund requests AND denials from Humana stating that they overpaid for bilateral ultrasound guidance services.
We have been billing 76881-LT/76881-RT for bilateral ultrasound guidance services.
Do any of you know why this is and what the basis is for the denials and refunds?

I read this on CMS:
"For Medicare claims, when reporting bilateral surgical procedures using codes where the termbilateral is not included in the descriptor, both the "Medicare Claims Processing Manual" andthe National Correct Coding Initiative (NCCI) manual specify that these bilateral surgicalprocedures should be reported using a single UOS and the -50 modifier. The NCCI manualgoes on to warn that MUE edits are predicated on the assumption that claims are coded inaccordance with these Medicare instructions. Consequently many bilateral procedures have anMUE value of 1, and have had that MUE value for some time.At the recommendation of the Office of the Inspector General (OIG), the Centers for Medicare& Medicaid Services (CMS) has examined its claims data relative to MUE levels and hasconfirmed a pattern of inappropriate billing using multiple lines to bypass the MUEs. Agreeingwith the OIG that this practice overcharges both beneficiaries and the Medicare program, CMSis converting most MUEs into per day edits. The MUE Adjudication Indicator (MAI) indicatesthe type of MUE and its basis. Effective with the July 1, 2014 update, published per day editsare identified on the CMS NCCI website (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html) by their MAI value of 2 or 3."

However, 76881 is NOT a surgical procedure AT ALL. I don't understand this denial.
They're asking for medical records to prevent the recoup from happening.
 
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812
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You're correct that it's not a surgical procedure; it IS however a diagnostic procedure. When looking into the modifiers for 76881, I found this information that may be helpful: 150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100% of the fee schedule amount for a single code."
 
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