Wiki Medicare not paying for 76881 when billed with other codes

[Biller2023]

We submitted 99213 (25 mod)+J7327+20611 (51 mod)+76881 to Medicare but 76881 was denied stating "This service/procedure requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present." and the remark code is M80 "Not covered when performed during the same session/date as a previously processed service for the patient."

How can we make medicare pay for 76881 also? Thank you!

 

[thomas7331]

CPT 20611 already includes ultrasound guidance of the injected joint so if your provider is billing 76881 for that same joint, then Medicare’s denial is correct. If 76881 was performed on a different joint from the one involved in 20611, then you would need a modifier on 76881 to indicate this. Also, I’d note that modifier 51 on 20611 is incorrect and unnecessary since only one surgical procedure is billed here.

 

[Biller2023]

Thanks. But 76881 was done for diagnosing the problem and 20611 was done for proper needle placement. Is there a modifier to indicate something like this or should I appeal with this reason?

 

[iowagirl77]

Thanks. But 76881 was done for diagnosing the problem and 20611 was done for proper needle placement. Is there a modifier to indicate something like this or should I appeal with this reason?

I don't believe it would be appropriate to bill the 76881 with 20611 for the same joint. Per NCCI Chapter 9, section H, #7:

Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service may be reported separately if the 2 procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (Ultrasonic guidance for needle placement...and interpretation) when performed in different anatomic regions on the same date of service. Physicians shall not avoid edits based on this principle by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service. Physicians shall not inconvenience beneficiaries nor increase risks to beneficiaries by performing services on different dates of service to avoid MUE or NCCI PTP edits.