Ob-Gyn Coding Alert

To get paid for both a transvaginal and pelvic ultrasound performed in the same session, proper documentation and correct modifier usage are crucial.

The Fort Collins Womens Clinic in Fort Collins, CO, routinely performs both the transvaginal and pelvic ultrasound during the same visit. Until recently, they were just filing for reimbursement for one of the procedures, using CPT code 76830 for the transvaginal procedure. In the last several months though they have been billing for two separate procedures using code 76830 for the transvaginal and 76856 for the pelvic ultrasound. More often than not payers have been paying for one service and denying the other. What is key in this scenario is charging and coding correctly while getting the maximum reimbursement.

The contention of the clinic is that both images are generally necessary to get a complete picture of the pelvic area. As Helene Stout of the Fort Collins Womens Clinic explains What you visualize with one imaging enhances what you see on another. We do the pelvic prior to the transvaginal in order to image the entire region. The challenge for Stout is that there is no CPT code that describes both procedures together.

The only ones weve had reimbursement at the outset are from commercial carriers says Stout. In every other case the claim for both has been initially denied and Stout has appealed every single decision. Her success rate with appeals has been mixed.

Documentation is Key

Thomas Kent CMM principal of Kent Medical Management in Dunkirk MD says that the problem is less one of coding than it is documentation. You need to have two separate reports for each ultrasound says Kent. These should be submitted with the claim to show that the first sonogram demonstrated the need for the second one. The reason the insurance companies wont pay for both explains Kent is that in their eyes the clinic is not showing support for giving two ultrasounds at same session. They think that if you do one you dont need to do the other. Showing a legitimate diagnostic reason for doing the second should ease reimbursement.

But Stout says that even with documentation reimbursement is still a problem. Whether or not the carrier pays says Stout seems to depend entirely on the carrier and never on the patients medical circumstances or the amount of documentation.

Modifier -51 and Modifier -22

Melanie Witt RN CPC MA program manager in the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG) feels that the most accurate way of coding for both procedures is to report both codes 76830 and 76856 and attach a -51 (multiple procedures) modifier to the second code. It does not matter which code goes first as the insurer views them as virtually identical.

You will never get a full reimbursement for the two procedures at the same time says Witt. But using the -51 modifier is the most true and accurate method of coding for this scenario and may lead to only a 50 percent discount in reimbursement.

One option for Stout and others like her is to code for the transvaginal ultrasound using CPT Code 76830 and apply a -22 modifier (unusual procedural services) although there are some questions about using the modifier. A -22 modifier will cause the claim to pendthe claim will get noticed by a reviewer. If sufficient documentation is submitted with the claim the reviewer is more likely to understand the circumstances behind ordering both procedures and reimburse a higher amount than for just the transvaginal alone.

Stout says the -22 modifier raises challenges as well. Sometimes the carrier rejects or challenges the -22 modifier. And of course with that were lucky to be reimbursed for half the cost of the pelvic ultrasound. Stout says that many carriers reimburse for the -22 modifier at as little as 25 percent of the coded procedure.
Witt also cautions that with the -22 modifier the office has to show that there was significant additional work done. Modifier -22 is not the default be all code says Witt. It is reserved for those instances when you are clearly trying to show that something unusual was going on.

While the patient has to be repositioned and the transducer inserted office expenses are not being duplicated. In the eyes of many insurance companies 76830 (transvaginal ultrasound) and 76856 (pelvic ultrasound) are identical in valueso you will never get full reimbursement for two procedures.

Using either the -22 or -51 modifier it appears that ob/gyn practices will have to show good reason through solid documentation for performing both ultrasound approaches and anticipate that they will be reimbursed at a reduced rate. Routinely conducting both the transvaginal and abdominal ultrasounds is not regarded as standard practice and therefore will always raise an eyebrow with the coding reviewer.

ACOGs Perspective on Issue

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