Reproductive Endocrinology Newsflash

New NCCI edits unbundle ultrasound reporting

Attention, reproductive endocrinology coders: You can now report 76830 together with 76856 or 76857 for the same visit without having to fight to get both services paid.
 
The National Correct Coding Initiative (NCCI), version 10.1, which took effect April 1, deletes an edit that previously bundled 76830 (Ultrasound, transvaginal) as a component of 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76857 (... limited or follow-up [e.g., for follicles]).
Why Unbundle?
 When similar procedures are performed together, NCCI sometimes considers the less extensive procedure to be included as a component in the more extensive procedure. In the past, NCCI considered 76830 to be a component of 76856 and 76857. However, CPT has always considered these codes "to be distinct services that can be delivered at the same session when medical necessity justifies doing both," says Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C. By deleting this bundling edit, NCCI provides "a more accurate reflection" of the correct coding procedure for using these CPT codes, she adds.
Use Modifier -51, Not -59
Before, you would have appended modifier -59 (Distinct procedural service) to get paid for both a transvaginal and transabdominal ultrasound in the same visit. Now that the codes are unbundled, you may need to append modifier -51 (Multiple procedures) to indicate to payers that you deserve reimbursement for both exams.
 
"Most payers do not require [modifier -51] for these services and reimburse each code at the full allowable amount," Richardson says. "Therefore, if a transvaginal ultrasound is performed in addition to a complete pelvic examination, it is appropriate to report both 76856 and 76830." Check with your payers for the requirements on reporting both codes and to see if modifier -51 is necessary.
 
Important: If a payer requires modifier -51 for reporting 76830 with 76856 and 76857, then you should place the modifier on the lesser-valued code, Richardson says. This will gain you better reimbursement because payers apply a discount to the procedure reported with modifier -51.
 
For example: Your reproductive endocrinologist (RE) schedules a woman for a transvaginal ultrasound to determine the precise cause of her infertility. During the exam the RE is unable to visualize all the necessary organs, so she decides also to perform a complete transabdominal ultrasound. You report 76830 and 76856. If your payer requires, you also append modifier -51 to ensure payment for both procedures.
Good Documentation Is Vital
Because the two ultrasound exams are so similar and have a history of being bundled, be prepared to support a claim for both 76830 and 76856 with adequate documentation. "It will be essential [...]

- Published on 2004-04-16