Wiki Anthem Policy Change 76942

[shari1264]

We are trying to bill 62232 and 64447 with ultrasound guidance (76942). The ultrasound guidance for the block is now being denied due to an Anthem policy change effective March 1st.

"In accordance with the Health Plans Modifiers 59 and XE, XP, XS, & XU (Distinct Procedural/Separate/Unusual Service) Reimbursement Policy, this code pair represents a mutually exclusive code-to-code relationship and only one code is eligible for separate reimbursement. Modifiers do not override this edit. Therefore, procedure 76942 is not recommended for separate reimbursement when submitted with procedure 62322."

Any suggestions on how to appeal so as to make them understand that the blocks are two separate procedures and that the ultrasound guidance only applies to 64447? One appeal has been denied already.

 

[LisaAlonso23]

The block should be billed with 59 & RT or LT, and 76942 needs a 26 modifier.

If the procedure was done under general anesthesia (GA) and it's documented that the surgeon requested the block to manage post-op pain, you can appeal using this information with the documentation.

If the procedure was not done using GA, then the block is considered integral to the anesthesia service and should not be billed separately.