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Maryland Medicaid denied 3 ultrasound CPT codes I coded

obinna Posted Thu 04th of June, 2015 11:44:38 AM

A family Practitioner that I work with did abdominal ultrasound (CPT code 76700) for abdominal pain, pelvic ultrasound (CPT code 76856) and transvaginal ultrasound (CPT code 76830) for uterine fibroid

This is what I came up with:

76700-(789.00-abdominal pain)
76856-(218.9-Uterine fibroid)
76830-(218.9-Uterine fibroid)

Maryland Medicaid denied this saying "PROVIDER TYPE INVALID FOR PROCEDURE"

I figured because the family practitioner had these done at his office and he's not a radiologist but then I read somewhere last night that if a private practice physician bills for these procedures at his/her private office, they can append a modifier (can't really recall what the modifier was).

If it's true, what modifier should I use and should I append it to all three of these ultrasound CPT codes?

Note: The Maryland Medicaid I'm referring to has this provider website: https://encrypt.emdhealthchoice.org/emedicaid/_Portal/provWelcome.jsp)

Hopefully the website will ring a bell.

SuperCoder Answered Fri 05th of June, 2015 01:47:32 AM

A family practice group may bill for the technical component on tests it performs for its own patients and permit an outside consultant to bill for the professional component. In such cases, the family practice group should append modifier -TC to the CPT code to indicate that it performed the technical component only. The consultant should append modifier -26 to the CPT code to indicate that he or she performed the professional component only, unless there are separate CPT codes for the technical and professional components only (e.g., 93005, “Electrocardiogram …; tracing only, without interpretation and report,” and 93010, “Electrocardiogram …; interpretation and report only).

However, the group may not bill globally for a service if it has purchased the professional component/interpretation from an outside consultant who reads the study off-site. A specific Medicare reassignment rule prohibits this type of arrangement. The family practice group may only bill globally for services that involve an outside consultant if that physician reassigns his or her right to payment to the group (becomes a member of the group for these purposes) and performs the interpretations at the office of the family physicians.

obinna Posted Fri 05th of June, 2015 12:28:57 PM

Ok in my own case, the family practitioner I work for hired a radiology tech to perform all these procedures in his office.

He points out what procedure (abdominal ultrasound, pelvic ultrasound etc) the radiology tech needs to do for whatever diagnosis and the lady performs the procedure right there in his office.

After the radiology tech performs these procedures, the family practioner has me bill for these procedures.

So given what I've just said now, how would I bill for these procedures?

Would I append modifier 26 or TC to all 3 procedures in this case?

SuperCoder Answered Mon 08th of June, 2015 03:27:20 AM

There are two ways of billing:

1. Radiology tech (who has been hired)can bill for the TC component and you can bill for the professional component (bill CPT codes with 26 modifier).

2. As mentioned in my last interaction, the practice group may only bill globally for services that involve an outside consultant if that physician reassigns his or her right to payment to the group (becomes a member of the group for these purposes) and performs the services at the office of the family physician.

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