Wiki Horizon BCBS denying 76942

Biller2023

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We billed 99213 with 25 mod + 76942 with 59 mod + 20551 with 51 mod + 76882 + J0702. All the codes were paid except for 76942 which was denied as CO-97 (benefit for the service included in the payment/allowance for another service/procedure already been adjudicated). I sent an appeal explaining 76942 (ultrasound) was done for proper needle placement (20551) and 76882 was done for diagnosing the problem but the appeal was upheld. How do we make Horizon BCBS pay for 76942 also. Is there a specific modifier we need to use. Thanks.
 
Hi there, have you thoroughly reviewed Horizon's policies to make sure they don't automatically bundle ultrasounds into another service? Remember that policies can be based on the place of service as well as the procedure.
 
Check into NCCI PTP edits. There's an edit between the 76882 and 76942. Has nothing to do with Horizon medical policies but they do utilize NCCI edits as part of their claims reimbursement edits. Anytime you have a bundled denial, NCCI edits should be the first place you look.
 
Check into NCCI PTP edits. There's an edit between the 76882 and 76942. Has nothing to do with Horizon medical policies but they do utilize NCCI edits as part of their claims reimbursement edits. Anytime you have a bundled denial, NCCI edits should be the first place you look.
I looked into the NCCI PTP edits, there are 4 links for the practitioner PTP edits, I clicked on the first one but I'm not sure what I should look for in this sheet.
 
I looked into the NCCI PTP edits, there are 4 links for the practitioner PTP edits, I clicked on the first one but I'm not sure what I should look for in this sheet.

First, I'll explain the spreadsheets: The 4 links are because the data is so large it is broken down into 4 files. If you look at the link titles, they contain code ranges. You'll want to open the one that would cover the radiology range (7XXXXX).

If you're not familiar with NCCI edits, the spreadsheet version can be hard to interpret. You'd search for your CPT codes in column 1, and column 2 would reflect any codes that edit against it. You can read more about how to interpret the data here: https://www.cms.gov/medicare-medica...-ncci/ncci-medicare/medicare-ncci-faq-library

However, I think it would make it easier on you and also assist with some of your other coding questions if your employer gave you access to an encoder. Most will allow you to type in 2 codes, hit return, and see if there are any edits against them.
 
By the way, from your original example, I see that you did use the 59 modifier on the 76942. There is an edit between 76882 and 76942, so you are correct that 76942 would need a modifier for payment if it was a separately identifiable service.

When you appealed did you send documentation for review?

There are more specific modifiers than 59 that can be used when initially billing a claim. However, if the payer has already reviewed the documentation and said that a separate payment isn't justified, then changing to an X modifier isn't going to change what happened during the documentation review.

Here's a link that explains the X modifiers vs 59 modifier for future reference though: https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xe-xp-xs-and-xu.pdf
 
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