Urology Coding Alert

Question: 76872 and 76942: Do we need to use modifier -25 to be paid for both of these on the same date of service? We have been resubmitting with a letter each time it has been denied as a duplicate service. If there is a way we can get paid without resubmission, please let us know.

Lisa Vaughan
Richard Nichols, MD, Calif.

  Answer: Modifier -25 is not necessary or appropriate in this case. In April 1997, the Health Care Financing Administrations (HCFA) Correct Coding Initiative (CCI) designated 76872 (echography, transrectal) as an integral component of 76942 (ultrasonic guidance for needle biopsy). Apparently, there were so many complaints that HCFA rescinded the edit.

The difficulty occurs because HCFA does not actually remove such edits. Instead, they establish an identical start and stop date. Some of the carriers do not get the message for the new stop date and continue to deny claims. I recommend you ask your Medicare carrier what CCI edits they have listed for this combination and what the start and stop dates are for each edit. If this does not resolve the problem, request a ruling from your regional HCFA office.