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76830 and 76856

  1. Default 76830 and 76856
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    per Encoder these 2 codes are not bundled. The report combines the findings into one but is clearly two approaches. The insurance I am having an issue with is Aetna. They are inconsistent however always bundle one into the other and only pay for one-sometimes the transvag and sometimes the pelvic ultrasound. When a 59 is appended to the bundled code(which goes against coding guidelines) the once-bundles/denied code is paid. I do not have this problem with any other carrier and get both codes paid first submission. Anyone else that can chime in or share their experience?

  2. Default
    The pregnancy status of the patient and the purpose of the ultrasound examination determine the proper code.
    Transabdominal ultrasound:
    When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic codes should be used (76815).
    When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric codes should be used (76857) and if it is for complete use- 76856.
    Transvaginal ultrasound
    Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
    If the patient is pregnant use the code (76817).
    If the patient is NOT pregnant use the code (76830).
    It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.

  3. Default
    I would like to give some info about COMPLETE and LIMITED, and the Modifiers US coding:

    A complete ultrasound exam is one that attempts to visualize and diagnostically evaluate all of the major structures within the anatomic region. For example, a complete abdominal ultrasound (76700) would consist of real time scans of the: liver, gall bladder, common bile duct, pancreas, spleen, kidneys, upper abdominal aorta and inferior vena cava.
    Many emergency department ultrasounds are more focused than "complete.
    " As defined by CPT, a limited ultrasound exam is one in which less than the required elements for a complete exam are performed and documented. Given the nature of of the focused ED ultrasound examinations, the limited codes are typically the most accurate for utilization in the ED setting. For example, an abdominal ultrasound used to evaluate the presence of an abdominal aortic aneurysm would be reported as a "limited retroperitoneal ultrasound" (76775).
    The one common exception to the rule is the transvaginal ultrasound in the pregnant (76817) and non-pregnant (76830) patient, where there is no corresponding limited procedure CPT.

    US Modifiers:
    The most common modifier used with ultrasound is probably the -26 Professional Component modifier.
    Ultrasound codes are combined, or "global," service codes that include both the technical component and the professional component. In the emergency department setting, the hospital will typically report the technical component that covers the cost of equipment, supplies, and personnel necessary for performing the service. The professional component is reported by the physician for the interpretation of the ultrasound and documentation of the results.
    There is nothing in CPT that prohibits the practitioner from also reporting the technical component (TC), if he/she provides all of the necessary elements. However, some payers with which the practitioner participates might have policies prohibiting payment of the TC to practitioners. For example, Medicare will not pay the technical component to hospital-based (but non-hospital-employed practitioners), even if the practitioners own the equipment, provide the supplies, and their personnel perform the technical service.
    Also, modifiers -76 and -77 (repeat procedure or service) possibly used in the setting of repeat scans as patients deteriorate (eg, AAA), or planned serial exams (eg FAST).

  4. #4
    Exclamation 76856 and 76830
    Aetna considers these, when done together " a standard of care" without each having a different diagnosis showing medical necessity for each done at same session.
    Has anyone had sucess appealing these denials?
    Aetna Policy.
    Susan Eosso, CPC,CPMA,CMRS

  5. #5
    Default multiple ultrasounds- same day
    I have just received a refund request from Group Resources (part of PHCS). they are bundling 76856 with 76830 and asking for monies back. Not real sure how to approach. The u/s are done for the same principal diagnosis so I can't use mod 59. Any advice?

  6. #6
    Did you appeal the request for the refund and if so, what happened? We are having a problem with two different carriers (UHC and Coventry) denying these two codes as bundled and they never did before recently. Thanks
    [COLOR="DarkOrchid"]Barbara Fontaine, CPC
    2011-2015 AAPCCA [B]Past Board of Directors Chair

    COLOR="Blue"]Assume Positive Intent...Be Kind!

    Past President St. Louis West Chapter


  7. Default
    Gather your clinical documentation and pursue with these payers who do not know the difference between a transvaginal or pelvic ultrasound. A few years back, I handled an appeal process with Aetna who requested a takeback on some procedures at an oncology practice. Needless to say with Aetna you will find that most likely the take back request was handled by a LPN or some type of nurse that may have coding experience but not in that field, therefore you really have a good chance of appealing this and winning with Aetna. I even included a a copied page out of the CPT book for their viewing and we won. Its clear as a crystal that these are two different procedures. Make sure your dx codes align with the reasoning to why the U/S is being done in both places. Good Luck and let me know how successful you are with this.

  8. #8
    Thanks Simone! We will gather it all up and appeal like crazy!
    [COLOR="DarkOrchid"]Barbara Fontaine, CPC
    2011-2015 AAPCCA [B]Past Board of Directors Chair

    COLOR="Blue"]Assume Positive Intent...Be Kind!

    Past President St. Louis West Chapter


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