Radiology Coding Alert

Find out which RAC is checking units for this code.

One of the challenges of radiology coding is knowing when you may report ultrasound imaging guidance separately. But capturing these opportunities is worth the trouble. For global 76942, the Medicare national price is $208.56. Review the rules below to ensure you’re bringing in every hard-earned dollar.

Dig Into Documentation Requirements

The code in focus is 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation).

To support coding ultrasound guidance, CPT^® section notes instruct that the medical record should include:

Permanently recorded images of the localized site

A description of the localization process.

Documentation: CPT^® specifies that the ultrasound guidance documentation may be either separately recorded or located "within the report of the procedure for which the guidance is utilized." 

Payers and CPT^® guidelines don’t offer much detail regarding what the documentation should include, other than requiring "a documented description of the localization process," says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the University of Pennsylvania, Department of Medicine, in Philadelphia.

CPT^® Assistant (March 2011) offers a bit of additional insight into the services required to support 76942. The code "requires that the ultrasound is used to guide the needle such as for a needle biopsy or fine needle aspiration (FNA) of an organ or body area. It is not required that the ultrasound guidance be used specifically for the insertion of the needle through the skin but the imaging must be used to guide the needle placement in order to report the code."

Watch for Reporting Restrictions

Even if your case meets the documentation requirements for 76942, you need to confirm that the code is reportable in addition to the code for the procedure requiring needle placement.

A note with 76942 states, "Do not report 76942 in conjunction with 27096, 32554, 32555, 32556, 32557, 37760, 37761, 43232, 43237, 43242, 45341, 45342, 64479-64484, 64490-64495, 76975, 0213T-0218T, 0228T-0231T, 0232T, 0249T, 0301T."

But the codes listed in the note aren’t the only ones you should be concerned about. Remember to also review code definitions and Correct Coding Initiative (CCI) edits to determine whether imaging guidance is separately reportable with the procedure.

Example: The "do not report" note with 76942 does not list 47490 (Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation). But CCI bundles 76942 into 47490. The edit makes sense because the 47490 definition states "including imaging guidance … and radiological supervision and interpretation."

Factor Fee Schedule Indicators Into Claims

Compliance with Medicare rules requires a careful review of the information in the Medicare Physician Fee Schedule. For 76942, you should understand two concepts in particular: professional/technical components and supervision requirements.

Professional/technical: When performed in a facility setting, such as outpatient hospital or emergency department, "the physicians may only report the professional component of radiology services (with modifier 26, Professional component). The facility will report the technical component," says Pohlig.

If the radiologist provides both the professional and technical components in an office setting, you should report 76942 without either modifier 26 or modifier TC (Technical component).

Personal supervision: The technical component of 76942 requires personal supervision, which means "a physician must be in attendance in the room during the performance of the procedure." You’ll find the above definition in the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80 www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.

Documentation should support the required level of supervision. For instance, for procedures requiring personal supervision, the progress note could include a comment by the supervising physician to document his presence in the room. Alternatively, a procedure room roster of participants, with time in and out recorded for each person, may suffice. Remember, the physician’s documentation also must meet requirements to support his overall involvement in the service provided.

Think ‘1 and Done’ for Medicare Units

Medicare gives 76942 a medically unlikely edit (MUE) of 1, which means that Medicare will deny the claim line if you report more than one unit on a line.

Physicians in California, Hawaii, and Nevada have additional incentive to ensure they’re complying with the MUE. Recovery Audit Contractor (RAC) Health Data Insights is reviewing physician claims in those states for improper reporting of more than 1 unit of 76942 for a single beneficiary on a single date. The RAC added the 76942 review to its list of approved issues in December of 2012. "Claims that have a ‘claim paid date’ which is less than 3 years prior to the Demand Letter date" are eligible for review.

Payer preference: Other payers may allow reporting of 76942 per lesion or have other unit requirements, so verify the payer’s policy if you’re unsure.

Apply the Details to Biopsy Examples

Code 76942’s definition makes it clear the code is intended to be used to report imaging guidance performed at the same session as another procedure requiring needle placement.

A single physician may perform and report both services. Alternatively, one physician may perform and report the imaging guidance, while a second physician may perform and report the surgical procedure. Final reporting will depend on the documentation and the contractual arrangements regarding the equipment and technical support used, Pohlig says.

Example 1: You may see ultrasound guidance used for a percutaneous renal biopsy, says Pohlig. Suppose the radiologist performs both the guidance and the biopsy in a facility setting. You should report 76942-26 and 50200 (Renal biopsy; percutaneous, by trocar or needle).

Example 2: Physicians also may use ultrasound guidance for percutaneous liver biopsy, Pohlig says. If the radiologist provides ultrasound guidance while another physician performs a liver biopsy in a facility setting, the radiologist should report 76942-26, and the other physician should report 47000 (Biopsy of liver, needle; percutaneous).