Wiki Prostate biopsy

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svanhorn73

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Help!

Our office bill 55700, 76942 and 76872 to Blue MCR. They denied 76872 stating that it is mutually exclusive to 76942. I called Blue Medicare and every time I call someone else gives me a different answer. is anyone seeing any denial for patients for Blue Medicare HMO. Its a NC plan? I forgot how to use that CCI edits on CMS'S website. What does the 9,1 and 0 mean again.

Thanks for any help you can give

Stephanie
 
During this biopsy, the doctor did a full rectal ultrasound and then used guidance for the prostate biopsy as well?? Seems like they would be bundled to me.


in the CCI table..

0 means you cannot bill the codes together (modifier not allowed to unbundle)
1 means you can bill both only IF you have the documentation (use a 59)
9 means...well pretty much, there is no edit, These are usually codes that used to be bundled, but are no longer. (technically a "0")
 
Thanks Linda....all codes are normally billed together. I got some documentation from another co-worker that prove that they all could be billed together. I also attached the meaning of the 0, 1, and 9
 
The American Urological Association has a letter you can print out and attach as part of your appeal to the insurance company in question. It's directed to the Medical Director and has a very thorough explanation of why each of these three codes is billable and payable. If you have access to auanet.org, go to Practice Resources, Appeal Letters, and then choose the letter that's titled "Transrectal Ultrasound Prostate Biopsy." Now, ome insurances have their own guidelines. For example, we have a couple where they won't pay on 76872 unless we use modifier -59. But definitely appeal. Hope this helps.

Zaida V. Aquino, CPC
 
Thanks I did get that letter from the AUA. I have forward it to them I have not received any reply from them. I will call them tomorrow.:)
 
This is how I charge these procedures out, it also depends if you own the equipment or not. 55700
76872
76942/59
I am reimbursed by all the payers.
 
I just wanted clarification please. Our urologist also when does a biopsy of the prostate uses these codes 55700, 76872 and 76942. He is only doing an op note in regards to the biopsy states that a transrectal ultrasound is performed and guidance is used.
Is a separate interpretation report required for the 76872 and 76942?
 
Does anyone have a suggestion on this please? I am just not clear on if our urologist is able to also bill out 76942 and 76872? Is a separate report required for each of these codes?
Or also if someone could point me to resources that might answer this question?
Thanks for your help
 
yes that is what we are charging also. If I may ask does your physician for the 76872 and 76942 do a separate report? Meaning separate from the procedure note? thank you
 
Possible solution

OK,

I personally have not billed Blue Medicare, but I was getting denials on the 76872. What I found to get all of them paid was:

55700 dx 790.93
76872 dx 600.10
76942 dx 790.93

And that has gotten all three codes paid when Cigna previously was considering the 76872 non-reimbursible when billed with 76942.

Now, I have a question for the other urology coders that bill prostate biopsies. Does anyone out there also bill the 88305 mod 26 for the obtaining of the specimen along with gross and mircoscopic examination. Or...the 88305 mod 26 for gross examination only?

Thanks,
Hunter Smith, CPC
 
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