Radiology Coding Alert

Question: Most insurance companies deny 76830 with 76856 unless I append modifier 59. But these codes aren’t bundled by CCI. How do we know if we need to append a modifier?

Codify Member

Answer: The Correct Coding Initiative (CCI) deleted the edit bundling 76830 (Ultrasound, transvaginal) into 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) several years ago. So Medicare and other payers applying CCI edits should not require you to append modifier 59 (Distinct procedural service) to 76830 to prevent a denial.

However, some private payers may opt to apply their own edits rather than using CCI’s. If the private payer edits aren’t available to you, then you can often discern them just as you have here by watching denials. You can then make a note in your coding resource about which payers require modifiers to report distinct services.

Smart move: Any time you report both 76830 and 76856, ensure documentation fully supports reporting both exams. Orders and medical necessity should be present for each. For instance, the record may show that the ordering physician required a clearer picture of the cervix than the transbdominal ultrasound could provide, and therefore a transvaginal exam was necessary. Documentation also should identify the findings for each separate exam.