76830 and 76856 -bundling issue
To get paid for both a transvaginal and pelvic ultrasound performed in the same session, proper documentation and correct modifier usage are very essential to be justified to the eyes of the payers.
Professionally and with medical necessity, most of the the pelvic organs and tissues necessitate both the ultrasound, to compliment each other for entirety of the structural visualization.
The approach is different and the transducers are different. One is done with the FULL BLADDER TECHNIQUE and the other is done after EMPTYING the bladder. One is done as a non invasive (on the integumentary) and the other is semi-invasive (ie transvaginal). In my opinion, it defintely cannot be bundled at all.
When the physician wants to have both, to compliment each other for better finding and decision making, not only for diagnosis but also for treatment modalities(options), why place stress to the coders? How can the payers validate the medical necessity of the scenario in a bundled way and limit the payment? It is not justified.
I feel the intricacies and the complexity of the female systems are not better understood with its entirety by some of the payers, if not most of them. The ob/gyn practices will have to validate with good reason through solid documentation for performing both ultrasound approaches, and anticipate that they will be reimbursed at a reduced rate, anyway. Though professionally with medical necessity, conducting both is mandated in most of the gynecological conditions in particular, the payer's spectrum of vision does not regard it as a mandatory/standard practice, and so will view it in an ‘angle of limitation'.
So, we need to have two separate reports for each ultrasound and for submission with the claim to show that the first one necessitated the need for the second, showing a legitimate diagnostic and /or procedural reason for doing the second to ease their justification and to potentiate the legitimate facility's/doctor's reimbursement.
A modifer -51 would be appropriate ( there is going to be a reduction for the second ultrasound anyway!) So which ever has a better RVU value, could be first placed and the modifier on to the second ultrasound code.
Thank you.