# Medicare CONTINUALLY denying 76942



## laurenortho (May 18, 2015)

Can someone *PLEASE* explain to me why Medicare allows CPT 76942 with code(s) J7321 and/or J7325 but then denies it every single time anyways?!

Yes, I've attached a 59 modifier to separate the two but it still does not good. It gets denied on every single patient, every time, as not 'medically necessary'.

Am I crazy or is there something I'm not doing? Oh and btw - Even my APPEALS are turned down. 

Is there a certain type of verbiage I'm supposed to be using in my appeal!?


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## mitchellde (May 18, 2015)

The 76942 is just ultrasound guidance.  If you are performing a joint injection you need the 20600-20611 codes. The ultrasound guidance is inclusive to the new codes and not billable.


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## laurenortho (May 18, 2015)

mitchellde said:


> The 76942 is just ultrasound guidance.  If you are performing a joint injection you need the 20600-20611 codes. The ultrasound guidance is inclusive to the new codes and not billable.


Debra - thank you for taking the time to respond.

According to the new provisions, J7321 or J7325 (among a few others) can NOT be billed with the new updated codes; 20611. It actually can ONLY be billed with 20610. Please reference LCD ID # L29307.

So with that being said, it specifically states that ultrasound guidance is only payable with supporting documentation indicating the medical necessity. 

Our documentation fully support medically necessity so I'm curious why it's still not payable.


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## BenCrocker (May 18, 2015)

Perhaps the DX doesn't jive?


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## laurenortho (May 18, 2015)

Oh, Ben -- how I WISH it were that easy!

Trust me, I follow the LCD's as closely as I can and make sure our provider's our aware also when treating patients. The diagnosis is not the issue, sadly.

See how frustrating this can be?!


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## mitchellde (May 18, 2015)

You cannot bill the 76942 with the 20610 code. I have billed Medicare with the 20611 for all large joint injections, all medications with no problems. I read the LCD and nowhere does it state you cannot bill 20611. For these injections.


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## dclark7 (May 19, 2015)

First, one suggestion, if you're posting a question about Medicare, please specify which MAC you have since each MAC has their own LCD and coverage policies.

 According to First Coast, 20611, 76492,77012,77021, 76881 and 76882 are *non-covered* services.  Fluoroscopy *may* be covered if properly documented.  Since I deal with both NGS JK and Palmetto I checked both of these LCD's to compare them with First Coast, neither of them list these codes as non-covered.  However, LCD #s L29307 for FL and L29408 for PR and FCSO Coverage News items state "The local coverage determination (LCD) for viscosupplementation therapy for knee contains the following language related to the non-coverage of imaging procedures (e.g., _20611, 77012, 77021, 76881, 76882_ or _76942_).
Imaging procedures performed *routinely* for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.
Therefore, these services will be denied."

So it seems if you have First Coast then these codes will not be paid even with modifiers.


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