Monday, August 2, 2010

CPT 76700, 76705, 76770, 76775, 76604, 76817 -Ultrasound procedure frequency limitation

Ultrasound Frequency Limitations

Reimbursement for the following Procedure-4 radiological ultrasound procedure codes is limited to four claims per year, for the same recipient, by any provider.  Additional claims for these codes must be accompanied with appropriate medical justification or the claim will be denied.


Procedure-4 Code    Description

76604    Ultrasound, chest (includes mediastinum), real time with image documentation

76700    Ultrasound, abdominal, real time with image documentation; complete

76705    limited (eg, single organ, quadrant, follow-up)

76770    Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

76775    limited


• 76817 Ultrasound, pregnant uterus, real time with image documentation,  transvaginal

• For gyn transvaginal ultrasound, use 76830


Billing and Coding Guidelines


Abdominal ultrasound examinations (Procedure codes 76700- 76775) and abdominal duplex examinations (Procedure codes 93975, 93976) are generally performed for different clinical scenarios although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure Procedure code should be reported with an NCCI-associated modifier.


Procedure Code           Bundled with            Rule       Formula Used to Determine Bundled Amount

76700   When any combination of column A codes are billed

 100% of the highest RVU, 50% of the second and 25% of the third or lesser RVU's



Procedure Codes 76700 & 76705 and ICD.10 code Z87.891 added to guideline. Replaced ICD.9 codes with ICD.10 codes in Examples of Claim Adjudication Scenarios section



Abdomen and Retroperitoneum Ultrasounds

Is a particular imaging study a limited or complete procedure? There are four ultrasound codes that can be challenging. Choosing an incorrect code could have an impact on reimbursement. The four codes are:

* 76700 - Ultrasound, abdominal, real time with image documentation; complete

* 76705 - ..........limited (eg, single organ, quadrant, follow-up)

* 76770 - Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; complete

* 76775 - ..........limited

Per Procedure, “A complete ultrasound examination of the abdomen (76700) consists of real time scans of the liver, gallbladder, common bile duct, pancreas, spleen, kidneys, and the upper abdominal aorta and inferior vena cava including any demonstrated
abdominal abnormality.”

Per Procedure, “A complete ultrasound examination of the retroperitoneum (76770) consists of real time scans of the kidneys, abdominal aorta, common iliac artery origins, and inferior vena cava, including any demonstrated retroperitoneal abnormality.” Alternatively, if clinical history suggests urinary tract pathology, complete evaluation of the kidneys and urinary bladder also comprises a complete retroperitoneal ultrasound.

• Trauma Ultrasound:

Currently, there are three Procedure codes which reflect separately identifiable elements of the FAST exam as described by the AIUM/ ACEP documents: 1) cardiac 93308-26, 2) abdomen 76705-26, and 3) chest 76604-26.


OB and Abdominal US

* Decision to order and perform an abdominal US is based on indications independent of the state of the patient's pregnancy status, even if the abdominal complication of a pregnancy is suspected (eg, pyelonephritis secondary to ureteral obstruction by a pregnancy or suspected cholecystitis in a pregnant patient with right upper quadrant pain).

* The abdominal ultrasound codes 76700, 76705 should be reported for an ultrasound of the abdomen when signs and symptoms indicate the necessity of an abdominal ultrasound procedure

LIVER ELASTOGRAPHY

X New code 91200 was added for liver elastography performed via mechanically-induced shear wave technique, such as vibration. The code includes interpretation and report, but not imaging. The code describes liver fibrosis evaluation, such as Fibroscan®, Philips® shear wave ultrasound elastography and other hepaticshear wave technologies. If performing ultrasound  with liver elastography, report using 76700, Ultrasound, abdominal, real time imaging documentation, complete, OR 76705, Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow up), AND 0346T, Ultrasound, elastography (list separately in addition to code for primary procedure).


Q: If a vascular study (with or without color Doppler) is performed in conjunction with ultrasound of the liver, is it appropriate to report both Procedure code 76705 (Abdominal ultrasound, limited) and Procedure code 93975 (Duplex scan of arterial inflow and venous outflow of abdominal, pelvic and/or retroperitoneal organs; complete study)? 


Yes, if an ultrasound of the liver is performed, and there is a clinical need for further evaluation by duplex scanning, then it is appropriate to code for both 76705 and 93975.

A vascular study (with or without color flow) may be reported in addition to ultrasound studies when it is clinically indicated (medically necessary). The radiology codes for ultrasound (e.g. abdomen, retroperitoneal, etc.) generally represent two-dimensional (gray-scale) imaging. For example, Procedure code 76700 includes gray-scale real-time or static images of the entire abdomen
from the diaphragm to the level of the umbilicus. If the study includes anything less than the allinclusive code 76700, then the limited code 76705 should be billed.


Sometimes a vascular study is added to the basic gray-scale study when enhancement of suspect areas or more detailed analysis is needed. Procedure code 93975 describes evaluation of arterial inflow and venous outflow of abdomen, retroperitoneum, scrotal contents and/or pelvic organs. This code can be used whether single or multiple organs are studied. It is a "complete" procedure in that all major vessels supplying blood flow (inflow and outflow, with or without color flow mapping) to the organ are evaluated. If the study is only a partial evaluation, then the limited code (93976) is billed. Therefore, in cases where it is necessary to perform a vascular study in conjunction with ultrasound of an organ, it would be appropriate to report the vascular study separately.

In order to code an abdominal duplex study, true vascular analysis needs to be performed. Abdominal duplex should not be coded when color is just turned on to determine if a structure is vascular (e.g., distinguishing hepatic artery from the common bile duct). Color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately.

4 Note that since January 1997, Medicare Correct Coding Initiative (CCI) edits have been in place for the vascular study codes (93975/93976) when used in conjunction with the pelvic ultrasound codes (76856/76857). Medicare considers these pairs to be mutually exclusive—that is, they should not be performed by the same physician, for the same patient, on the same date of service. The code pair edits do list a modifier indicator of "1" with the vascular study codes (939751 ,939761 );  therefore, it would be appropriate to submit these codes together with a modifier attached to the vascular study code (e.g., 93975–59 or 93976–59). For example, a patient comes in with pelvic pain, and the ultrasound of the pelvis demonstrates an enlarged ovary. The differential diagnosis includes torsion of the ovary. A vascular study is requested to establish the arterial inflow and venous drainage of the ovary and determine torsion or infarction. In this scenario, it would be appropriate to code 76856 for the pelvic ultrasound and 93976-59 for the limited vascular study of the ovary.

Billing of CPT 93306 and 76604 example:

Reimburse for:

93306 – Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography and with color flow Doppler echocardiography.

Deny:

76604 – Ultrasound, chest (includes mediastinum), real time with image documentation.


• For diagnostic ultrasound of the chest, including mediastinum use CPT code 76604. This code is used for the evaluation of the pleural spaces for the presence of fluid and/or masses of the chest, chest wall or mediastinum.


Abdominal Aortic Aneurysm Screening Procedure Code(s): 76700, 76705, 76770, 76775, G0389 Diagnosis Code(s):

• ICD-9: V15.82

• ICD-10: Z87.891, F17.210, F17.211, F17.213, F17.218, F17.219

Age 65 – 75 (ends on 76th birthday) Anemia, Iron Deficiency Anemia Screening



Corrections to skilled nursing facility consolidated billing codes

When change request 7159 (2011 Annual Update of Healthcare Common Procedure Code System (HCPCS) Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update) was implemented in January 2011, a few codes were not included in the claim processing system edits. A correction to add the codes listed below to the claims processing system edits was implemented on Monday, March 14, 2011.

Providers who submitted claims for these services before Monday, March 14, 2011, may have had claims incorrectly denied. Providers who believe they received an incorrect denial should contact their Medicare carrier or Medicare administrative contractor (MAC) to have the claims reopened and reprocessed. Claims containing any of the codes below that were processed on or after Monday, March 14, 2011, will process correctly. Additional questions should be directed to your Medicare carrier or MAC.

The affected HCPCS codes are as follows: 76519, 76529, 76536, 76604, 76645, 76700, 76705, 76770, 76775, 76800, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, 76870, 76872, 76873, and 76876.


Abdominal Ultrasound and FAST Exam

• To bill for the evaluation of a single organ within the abdomen use code 76705 (abdominal ultrasound, limited or follow-up). To bill for Focused Abdominal Sonography for Trauma (FAST) exam, also use code 76705.

• For ultrasound guidance of a needle procedure to any abdominal organ, use 76942. Report 76942 in addition to the code for the primary procedure (e.g., 49080).

Vascular Ultrasound

• For evaluation of carotid arteries, use codes 93880, duplex scan of extracranial arteries, complete bilateral study or 93882, unilateral or limited study.

• For evaluation of extremity veins for venous incompetence or deep vein thrombosis, use codes 93970, duplex scan of extremity veins; complete bilateral study or 93971, unilateral or limited study.

• Medicare has created code G0365 to be used for vessel mapping for hemodialysis access. The code includes evaluation of the relevant arterial and venous vessels.

• The limited extremity venous duplex code (93971) is used for all other vein mapping. Check with your payers for coverage guidelines on this procedure. In some cases it is not paid in the absence of a previous condition such as severe varicose veins or previous deep vein thrombosis.

• CPT codes 36475, +36476, 36478, +36479 are used to describe saphenous vein ablation procedures using the radiofrequency and laser methods. These codes are inclusive of all imaging guidance; ultrasound guidance of these procedures is not separately reportable. Although carrier policies vary, typically preoperative extremity duplex to identify and characterize the venous incompetence can still be reported separately. The recommended codes for that procedure are 93970 and 93971 – Duplex scan of extremity veins, depending upon whether the study is complete and bilateral or limited and unilateral.

• If the technical component services of the vascular studies are performed by sonographers, some Medicare Carriers require that the your local carrier’s non-invasive vascular ultrasound coverage policy to learn their requirements. The credentialing requirement does not apply if the physician performs the technical component of the vascular study.

Attachment C: Billing Guidelines for Ultrasounds for Multiple Fetuses

When billing for the ultrasound of multiple fetuses, the following guidelines should be observed.

1. The primary transabdominal code must be billed as one detail with one unit of service. (These codes are 76801, 76805, and 76811.)
2. The add-on code must be billed on one detail line with the units of service equaling the number of additional fetuses (76802, 76810, and 76812).
3. Each add-on code must be billed with the correct primary code.
4. The add-on codes for “each additional fetus” must be billed with the appropriate multiple gestation ICD-10-CM codes from the table below. (Do not use the fifth-digit subclassifcation digit 0.) The units billed for the add-on ultrasound procedure code is based on the number of “each additional” living fetus(es).
5. One combination of primary and add-on ultrasound codes is allowed per day. Claims denied for additional ultrasounds may be resubmitted as an adjustment with documentation to support the medical necessity of a repeat ultrasound on the same date of service.
6. 76815 is defined to include “one or more fetuses” and can only be reimbursed for one unit of service.
7. When billing 76816 for multiple fetuses, bill 76816 on one detail without a modifier and with one unit for the first fetus. Additional fetuses must be billed on the next detail line using 76816 with modifier 59; the units should equal the number of additional fetuses. This code  must also be billed with the appropriate diagnosis code from ICD-10-CM series of diagnosis codes outlined above.
8. In addition to the transabdominal ultrasounds, one unit of 76817 is covered on the same date of service if medically necessary. No modifier is needed. Medical necessity must be documented in the beneficiary’s medical record.
9. Fetal biophysical profiles (76818 and 76819) are covered for additional fetuses. The profile for the first fetus must be billed on one detail, no modifier, and one unit of service. Profiles for additional fetuses must be billed on the next detail, using modifier 59, with the number of units equaling the number of additional fetuses. The appropriate diagnosis code from the 651 series should be billed as outlined above.
10. Claims for fetal biophysical profiles submitted with more than one unit and without the appropriate diagnosis code will be denied. Providers should correct the claim and resubmit as a new claim.
11. Claims for multigestational transabdominal ultrasounds submitted without the appropriate diagnosis will be denied. Providers should correct the claim and resubmit as a new claim.
12. Medical records are required for multiple gestation diagnosis codes from the ICD-10-CM series outlined above that note “fetal loss” or “other” and/or “unspecified multiple gestation.”
13. In cases of fetal demise, the ultrasound procedure that confirms the loss of one, or more, fetuses may be billed with units to include the total number of additional fetuses, dead and living. Subsequent billings should be billed with the units based on the number of “each additional” living fetus.
14. A fetal biophysical profile must not be billed for a fetus that has died.
15. CPT code 76830 must not be billed for a transvaginal ultrasound performed for any pregnancy related condition.
16. Because pregnancies with multiple fetuses are high-risk pregnancies, there is no limit to the number of ultrasounds performed during the pregnancy when billed according to these instructions. However, excessive billing of ultrasounds during a pregnancy is subject to postpayment review for medical necessity, which must be documented in the medical record.

Limited obstetric ultrasound enhancement program

(HMO, Aetna Health Network Only plans and Aetna Health Network Option plans) Obstetric care providers who participate in the limited obstetric ultrasound enhancement program perform all  necessary limited (first, second or third trimester) ultrasounds in their offices and receive an enhancement to their global obstetric fee, regardless of the number of limited ultrasounds performed. These ultrasound CPT codes include:

• 76801
• 76802
• 76815
• 76816
• 76817

Note: Complex obstetric ultrasounds (CPT codes 76805, 76810, 76811 and 76812) aren’t included in this program. To be compensated for performing these “complete” scans, physicians can participate in the complete obstetric ultrasound enhancement program described in the next section. Physicians who elect not to participate in either ultrasound enhancement program should send members who need these scans to participating radiology centers, facilities or perinatologists. Referrals or prior authorizations aren’t necessary for anatomic or “complete” ultrasounds.

Note: Ultrasounds to measure nuchal translucency (CPT codes 76813 and 76814) aren’t included in this program. CPT codes 76813 and 76814 can be performed in the office on a fee-for-service basis by credentialed clinicians. Complete obstetric ultrasound enhancement program  (HMO, Aetna Health Network Only plans and Aetna Health Network Option plans) Obstetric care providers who participate in the complete obstetric ultrasound enhancement program perform all necessary obstetric ultrasounds in their offices and receive an enhancement to their global obstetric fee, regardless of the number of ultrasoundsperformed. These ultrasound CPT

codes include:
• 76801
• 76802
• 76805
• 76810
• 76815
• 76816
• 76817

CPT codes 76811 and 76812 aren’t included in this program, but are included in the global obstetric fee.

If a physician participating in the complete obstetric ultrasound enhancement program needs a “targeted” or second-opinion ultrasound, he or she can send the patient directly to a participating radiology center, facility or perinatologist for these studies. Under this program, referrals or prior authorizations aren’t necessary for targeted or second-opinion ultrasounds.

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