Ob-Gyn Coding Alert

Question: I'm trying to bill an ultrasound using 76831/76856. The explanation of benefits (EOB) states, "For processing purposes, the service line has been recoded from the global service to the professional and technical component lines." When I check the sum of the professional and technical payment amounts, the amount is less than the amount in our fee schedule. Is this a violation of our contract and a way to avoid paying the contracted rates? How should I combat this?

Florida Subscriber

Answer: Contact your carrier and inform them you will appeal each and every claim where you use 76831 (Saline infusion sonohysterography [SIS], including color flow Doppler, when performed) and 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete).

If that doesn't work, notify them they are in violation of your contract, and you will be seeking redress via your state medical association, your state legislators, and the state insurance commissioner. Also, make sure you carbon copy (cc:) these people in your letter and send the letter directly to the medical director of the plan. If that fails, contact the American College of Obstetricians and Gynecologists (ACOG) and fill out its payer complaint form.

Heads up: You may have another issue on your hands altogether, even though the denial message seems to indicate the carrier is merely splitting the fee between the two components. The Correct Coding Initiative (CCI) does not bundle codes 76856 and 76831, but for some payers, this is a bundling issue. Make sure that Cigna is not one of these and if it is, apply modifier 59 (Distinct procedural service)  to 76831 so long as your ob-gyn's documentation clearly shows that each was a distinct ultrasound with separate documentation and findings.

-- The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.