# Billing CPT 76000



## mdameer159@gmail.com (Aug 2, 2018)

Hello all,

Scenario: Provider is performing Posterior & Posterolateral Technique Arthodesis. And in this procedure, fluoroscopy is not included. Hence, provider has billed CPT 76000. As per the description of the billed CPT 76000, timing of UPTO 1 HOUR should be documented. But, when time is not documented, do we still need to pay out the service as it was rendered or do we need to deny stating there is no time documented?

Any answer will be grateful.

Thanks & Regards
MA


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## Jim Pawloski (Aug 2, 2018)

mdameer159@gmail.com said:


> Hello all,
> 
> Scenario: Provider is performing Posterior & Posterolateral Technique Arthodesis. And in this procedure, fluoroscopy is not included. Hence, provider has billed CPT 76000. As per the description of the billed CPT 76000, timing of UPTO 1 HOUR should be documented. But, when time is not documented, do we still need to pay out the service as it was rendered or do we need to deny stating there is no time documented?
> 
> ...



To quote what I read; If it is not documented, it didn't happen. So if the doctor didn't state the use of fluoroscopy, you don't bill it. But you can ask the doctor if he used fluoroscopy and didn't dictate it, to make an addendum stating fluoroscopy was used. After that, you can bill it.
HTH,
Jim Pawloski, CIRCC


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## mdameer159@gmail.com (Aug 3, 2018)

Thanks Jim Pawloski for your time.

Adding a point on your comment, provider has rendered the service(Fluoroscopy) and billed CPT 76000. But, time isn't documented. What shall be the appropriate action? Can we pay the service or do we need to deny the service for not documenting the required time. Thanks

Regards
MA


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