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sam Posted Mon 18th of December, 2017 16:01:57 PM
We're receiving denial reasons for POS 24 for CPT 72275 that it cannot be billable at POS 24 without modifier 26. We need to know the correct billing guidelines that is it compulsory to append modifier 26 in front of CPT 72275 when billed with 64483 with modifier 50 and the services were also rendered by the same provider. Please share you experience Thank You!
SuperCoder Answered Tue 19th of December, 2017 01:08:13 AM


Use CPT code 72275 only when an epidurogram is performed, images documented, and a formal radiologic report is issued. There may be rare instances where one provider supervises the radiology service and another provider interprets it. According to Medicare guidelines, each provider should report the radiology code and append reduced service modifier 52. Each should also append modifier 26 to the code to report only the professional component. Do not report fluoroscopic guidance separately using 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid] [List separately in addition to code for primary procedure]).

Below CPT 72275 for Medicare is found in addendum BB for ASCs. Addendum BB are services that are considered packaged and no separate payment is made. CPT 72275 has a status indicator on the facility side for Medicare as N1. N1 Packaged service/item; no separate payment made. Additionally below I copy and pasted the state operations manual describing the ASC as providing surgical services and certain services are considered ancillary. Procedures such as discograms or myelograms are not covered in ASCs for Medicare because they have a primary diagnostic purpose. The concern that you would want to review is the procedure actually for the purpose of diagnostic epidurogram or is it more of the contrast is being injected with limited notation of the structures, but the primary purpose is therapeutic. Typically CPT 72275 is not going to be covered and the reason for the epidural is therapeutic.


Addendum BB -- Final ASC Covered Ancillary Services Integral to Covered Surgical Procedures for CY 2015 (Including Ancillary Services for Which Payment is Packaged)
CPT codes and descriptions only are copyright 2014 American Medical Association.* All Rights Reserved.* Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2014 American Dental Association.* All Rights Reserved.

Exclusive Provision of Limited Surgical Services 
The ASC must offer only surgical services. Separate ancillary services that are integral to the surgical services, i.e., those furnished immediately before, during or immediately after a surgical procedure, may be provided. The ASC may not, however, offer services unrelated to the surgeries it performs. 
What constitutes ?surgery?? 
For the purposes of determining compliance with the ASC definition, CMS relies, with minor modification, upon the definition of surgery developed by the American College of Surgeons (www.facs.org/fellows_info/statements/st-11.html.) Accordingly, the following definition is used to determine whether or not a procedure constitutes surgery: 
Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated by closed reductions for major dislocations or fractures, or otherwise altered by mechanical, thermal, light-based, electromagnetic, or chemical means. Injection of diagnostic or therapeutic substances into body cavities, internal organs, joints, sensory organs, and the central nervous system, is also considered to be surgery. (This does not include the administration by nursing personnel of some injections, subcutaneous, intramuscular, and intravenous, when ordered by a physician.) All of these surgical procedures are invasive, including those that are performed with lasers, and the risks of any surgical procedure are not eliminated by using a light knife or laser in place of a metal knife, or scalpel.


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