Rebecca Posted Wed 29th of January, 2020 10:17:34 AM
PHYSICIAN PERFORMS A DIAGNOSTIC BREAST ULTRASOUND 76642-LT ON A PATIENT . THAT SAME DAY SHE DOES AN FNA ON THE SAME LESION WITH ULTRASOUND GUIDIENCE 10005-LT. CANWE BILL FOR BOTH ? AND WOULD WE NEED A MODIFIER ON ONE ? WHAT IF ON THE SAME DAY THE PHYSICAIN PERFORMS ANOTHER DIAGNOSTIC ULTRASOUND ON THE SAME BREAST AND FINDS A LUMP/MASS THAT SHE DOES AN ULTRASOUND GUIDED CORE BIOPSY ON ……..19083-LT, 100O5-LT, 76642-LT (I BELIEVE 76642 CAN ONLY BE BILLED ONCE) PHYSICIAN PERFORMS A DIAGNOSTIC BREAST ULTRASOUND 76642-LT ON A PATIENT . I HAD AN INSURANCE(BCBS)WITH DENY PAYMENT FOR 76942 WHEN I BILLED 19000-RT, 76642-RT(DIAGNOSTIC ULTRASOUND) AND 76942-RT ….I WANT TO SAY THAT THERE MAY BE AN NCCI EDIT THAT STATES IF A DIAGNOSTIC PROCEDURES RESULTS IN A THERAPEUTIC PROCEDURE THAT YOU CAN BILL FOR THE DIAGNOSTIC PROCEDURE...… I NEED CLARIFICATION ON THIS TY FOR YOUR HELP
SuperCoder Answered Thu 30th of January, 2020 06:35:09 AM
When both the procedures are performed in the same session, it would be difficult to get paid, but when diagnostic breast ultrasound and ultrasound guided FNA performed in the different session, it should pay with the help medical necessity documents.
On the other hand, when another ultrasound is performed on the same day, then it will not be paid until there is strong medical necessity. Also, in procedure 19083 and 10005, ultrasound and biopsy are the common components, so, make sure to provide the supportive documents to get the proper reimbursement. However, code 10005 is a column 2 code for 19083, but you may use a CCI-associated modifier to override the edit under appropriate circumstances.
For the previous claim of BCBS, ultrasound is the common component between the code 76942 and 76642, so it might had denied due to commonality. Denial also depends on the situation in which both the codes billed or on the basis of any specific guidelines. You can check the EOB of the claim for the accurate reason of denial.
Hope this helps!
Rebecca Posted Thu 30th of January, 2020 14:46:11 PM
TY this does help. Just want to make sure I understand "performed in the different session" How is this defined …..do they mean a different time of the day ? if a diagnostic ultrasound is done and ten 10 mins later the FNA with imaging guidiance is done ……..am assuming that doesn't constitute a "different session" just want to make sure am clear on this ty As for billing 10005 and 76642 if I wanted try this what would be the best modifier 59 or if a different session was justified would it be XE ? which code would get the modifier 19083 or the 76642 ? as for billing 19083 and 10005 on the same day for different lesion …. just want to make sure on clear I understand the CPT guidelines so it would be billed like this ( we would be using ultrasound guidance for both) 19083 10005-59
SuperCoder Answered Fri 31st of January, 2020 05:28:17 AM
Hope you are keeping well.
A gap of 10 minutes will not be considered as the different session. Different session considered when there is re-preparations of procedure and remarkable time gap. Yes, it would be appropriate to use of XE modifier with any of the procedure you consider as distinct because it occurred during a separate encounter.
For CPT 19083 and 76642, there is no CCI bundling between the codes, however, ultrasound is already a part of CPT 19083. On the other hand, code 10005 is a column 2 code for 19083, usually modifier is appended to the column 2 code, but as per modified guidelines by CMS, you may use a CCI-associated modifier to override the edit even with column 1 code when documentation supports under appropriate circumstances.
Apart from this, it is suggested to check your payer's specific guidelines and bill accordingly.
Hope this helps!
Rebecca Posted Mon 03rd of February, 2020 10:13:04 AM
Got it TY I just wanted to make sure I was crystal clear :)
Rebecca Posted Mon 03rd of February, 2020 10:52:06 AM
just out curiosity what constitutes a different session ? i realize a different day and possibly doing the diagnostic ultrasound in the AM and then doing US guided FNA in the afternoon 76642-XE , 10005 would the XE go on the 76642 ....right ? so there is a CCI edit for 10005 and 76642 correct ? but there is no CCI edit for 10083 and 76642 TY :)
SuperCoder Answered Tue 04th of February, 2020 05:59:52 AM
Hope you are doing good.
Situation based; it stands for different session. However, there is no CCI edits between the codes 10005 and 76642. But to differentiate between the procedure, modifier XE can be added to define the procedure as separate encounter. Modifier XE tells about the service that is distinct because it occurred during a separate encounter. Also, there is no CCI edits between the codes 19083 and 76642, but ultrasound is already a part of CPT 19083. So, check the medical necessity of the procedure and bill accordingly.
Rebecca Posted Tue 04th of February, 2020 12:49:21 PM
SuperCoder Answered Tue 04th of February, 2020 23:34:54 PM
Thank you, happy to help.