Wiki Modifiers for multiple 76942, ultrasound?

[sopka9476]

I have always charged for both ultrasounds performed on different anatomical sites during a single visit and just earlier this year have started receiving denials on the second US. For example, bilateral knee injections or a knee injection and a shoulder injection done where US guidance for needle placement was used for each injection site. For the bilateral procedure I coded as:76942-RT, 76942-LT and that is no longer being accepted. My appeal letters have gotten me no where. I am aware of the NCCI edit for 76942 allowing one unit at a single encounter but the disclaimer states a modifier can be used to override edit:

CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, NOT number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.

The CMS instruction is that imaging guidance is billed once per encounter and not per lesion. Society guidelines have always defined imaging guidance as reported per lesion or anatomical area involved.

This edit will allow use of NCCI associated modifiers if 76942 is utilized for a separate procedure unrelated on the same date of service.
Would modifier -59 be appropriate? Need help please!
Thanks

 

[ollielooya]

I don't know if modifier 59 will actually override the editis in this case. I'm assuming this is MCR, right? The MUE's only alllow one per service, and this is what you're bumping up against. Some time ago there was a discussion about utilizing modifier "GD" to help with these type of issues. Our carrier NGS doesn't recognize it, but if they did would be sure to use it. Not much written about this modifier, and don't know if it was ever initiated, and I didn't get much response when I posted this to the forum. I think it may have been sunsetted before it was actually activated?! Unfortunately, the only way the physicians may be paid is if they schedule the patient to return. Not the best way to do business....I feel your pain.....

 

[donnajrichmond]

If the patient has Medicare it is not appropriate to add modifier 59 to 2nd + 76942 for services provided at the same session. The policy is very clear. Nor would it be appropriate to split the services into separate sessions so that you could get paid for each 76942.