# 76942 billing



## lcole7465 (Jun 7, 2019)

My pain doctor does procedures in the ASC and takes his own ultrasound machine down to use. Would I be able to bill 76942 globally with no modifier (-26) since he is using his machine and not the ASC's. 

I have a claim that the insurance has denied for invalid modifier for this code. 

Thank you for any input


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## CodingKing (Jun 7, 2019)

Technical component is a facility expense thus only professional component can be billed by physician. Does the facility not own an ultrasound machine? If not he needs to work out a deal with the ASC to reimburse him for the technical component.


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## dwaldman (Jun 8, 2019)

Site of Service 
Physician Office (Medicare Physician Fee Schedule (MPFS)) In the office setting, a physician who owns the equipment and performs the ultrasound guidance may report the global/ nonfacility code and report the CPT code without any modifier. 

Hospital Outpatient or Ambulatory Surgery Center (ASC) If the site of service is a hospital outpatient setting or an ASC and the physician is performing the ultrasound guidance, the -26 modifier (professional service only) should be appended to the CPT code for the imaging service. Based on the Medicare Outpatient Prospective Payment System (OPPS), the technical component of image guidance for a needle placement procedure that is performed in the hospital outpatient department or in the ASC is considered a packaged service. This means that the payment to the facility for these services is included in the payment for the primary procedure.



			https://www3.gehealthcare.com/~/media/downloads/us/ultrasound_point_of_care_reimbursement_advisory.pdf
		


Above is from GE ultrasound reimbursement guide. Below is from the Medicare claims processing manual for ASCs Chapter 14. Medicare or Medicare Advantage plans consider CPT 76942 to have a N1 status indicator in ASCs.  N1 rrepresents services that are considered packaged into the surgical procedure and no separate payment is made. So "technically" the facility is getting reimbursed within the primary CPT for the use of the ultrasound. This corresponds with the hospital setting which this CPT has a N status indicator and it is packaged.










Packaged service/item; no separate payment made.












			https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c14.pdf
		



ASC services for which payment is included in the ASC payment for a covered surgical procedure under 42 CFR 416.166 include, but are not limited to- 

(a) Included facility services:
 (1) Nursing, technician, and related services; 
(2) Use of the facility where the surgical procedures are performed; 
(3) Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver; 
(4) Drugs and biologicals for which separate payment is not allowed under the hospital outpatient prospective payment system (OPPS); 
(5) Medical and surgical supplies not on pass-through status under Subpart G of Part 419 of 42 CFR; 
(6) Equipment; 
(7) Surgical dressings; (8) Implanted prosthetic devices, including intraocular lenses (IOLs), and related accessories and supplies not on pass-through status under Subpart G of Part 419 of 42 CFR; 
(9) Implanted DME and related accessories and supplies not on passthrough status under Subpart G of Part 419 of 42 CFR;
 (10) Splints and casts and related devices; 
(11) Radiology services for which separate payment is not allowed under the OPPS, and other diagnostic tests or interpretive services that are integral to a surgical procedure; 
(12) Administrative, recordkeeping and housekeeping items and services; 
(13) Materials, including supplies and equipment for the administration and monitoring of anesthesia; and 
(14) Supervision of the services of an anesthetist by the operating surgeon. 
Under the revised ASC payment system, the above items and services fall within the scope of ASC facility services, and payment for them is packaged into the ASC payment for the covered surgical procedure. ASCs must incorporate charges for packaged services into the charges reported for the separately payable services with which they are provided. Because contractors price ASC services based on the lower of submitted charges or the ASC payment rate for the separately payable procedure, and because this comparison is made at the claim line-item level, facilities may not be paid appropriately if they unbundle charges and report those charges for packaged codes as separate lineitem charges 

Covered ancillary items and services that are integral to a covered surgical procedure, as defined in 42 CFR 416.61, and for which separate payment to the ASC is allowed include: (b) Covered ancillary services 
(1) Brachytherapy sources; 
(2) Certain implantable items that have pass-through status under the OPPS; 
(3) Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue; 
(4) Certain drugs and biologicals for which separate payment is allowed under the OPPS; 
(5) Certain radiology services for which separate payment is allowed under the OPPS.


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