For years Medicare has accepted these codes for a prostate ultrasound and biopsy with no bundling issues. This is the order we billed them 76872, 55700, 76972. Since July I have been getting flagged that 76942 is a component of 76872 and a modifier is allowed to differentiate between the services provided. We have never had to use a modifier in the past. Has anyone else noticed this?
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Wiki Since when does Medicare bundle 76942 with 76872
- Thread starter michelleaapc2012
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danskangel313
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From what I've read, it seems like every couple of years this edit turns on, then it'll turn off again a while later. 
Nonetheless, the consensus seems to be that an appeal needs to be done.
I checked the edits and it says:
Code 76942 is a column 2 code for 76872 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 76942
CCI edit Rule:
Misuse of column two code with column one code
Nonetheless, the consensus seems to be that an appeal needs to be done. I checked the edits and it says:
Code 76942 is a column 2 code for 76872 , but a modifier is allowed in order to differentiate between the services provided.
*Use modifier with code 76942
CCI edit Rule:
Misuse of column two code with column one code
ashumate11
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The National Correct Coding Initiative indicates this edit (76942 bundled with 76872) became effective July 1, 2016. I am going to try billing CPT 76942 with modifier -59, since our documentation supports the billing of both codes. I will post the outcome here once I receive my EOB from Medicare.
JEYCPC
Expert
Definitely submit 76872 and 76942-59 for the CCI edit. Remember that the documentation must support the modifier.
NCCI Edits 76872 and 76942
The edit line within NCCI edit is now a number 9.
76872 76942 19970401 19970401 9 Standards of medical / surgical practice
You will have to ask for a re-determination. They have retroactively changed from a 1 to a 9 and will acknowledge a system problem.
The edit line within NCCI edit is now a number 9.
76872 76942 19970401 19970401 9 Standards of medical / surgical practice
You will have to ask for a re-determination. They have retroactively changed from a 1 to a 9 and will acknowledge a system problem.
KelliAnnis
New
We are having the same issue with the bundling; do you have an update to this? Also, do you have an example of proper documentation for both procedures that I can use to compare to our physician? Thanks!
2017 NCCI Manual re: 76942 and 76872
2017 NCCI Manual
Page 246
Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable. For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.
http://www.auanet.org/practice-reso...resources-and-information/prostate-procedures
American Urological Association
Prostate Procedures
Q. Prior to transrectal guided prostate biopsy; my urologist performs a transrectal ultrasound to establish medical necessity to proceed with the prostate biopsy. The CPT® codes billed are transrectal diagnostic ultrasound (CPT® 76872), the sonographic guidance (76942) and prostate biopsy (55700). Some insurance companies are bundling the two ultrasound codes as incidental. Is there something we can do to convince carriers to pay these three codes?
A. Correct Coding Solutions, Medicare contractor for the National Correct Coding Initiative (NCCI), issued their final decision to bundle CPT code 76942 Ultrasonic guidance for needle placement paired with CPT codes describing diagnostic ultrasound procedures (specific for urology, CPT code 76872 Ultrasound, transrectal). Their decision was issued in a November 17, 2016 letter to the AUA after AUA questioned the contractor’s original edit that was implemented on July 1, 2016. The AUA also had participated on a conference call with the NCCI and Center for Medicare & Medicaid Services (CMS) representatives and requested that the edit be removed stating that these imaging procedures are performed for separate and specific reasons. The AUA believed that the edit would create erroneous denials.
However, after several attempts by the AUA to change the edit, CMS has updated the 2017 version of the National Correct Coding Initiative Policy Manual with the codes bundled. The following has been posted to the CMS NCCI website stating in Chapter 9 Radiology, Section H General Policy Statements, “Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable. For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service."
The AUA is recommending that providers should consider reporting either CPT code 76872 Ultrasound, transrectal; or CPT code 76942 Ultrasonic guidance for needle placement based on the procedure performed and the documentation in the patient’s chart. A modifier should not be used to unbundle this coding scenario as it has been deemed inappropriate coding.
CMS to Uphold Edit to Bundle Transrectal Ultrasound and Ultrasonic Guidance
By Policy and Advocacy Brief posted 12-07-2016 15:09
2017 NCCI Manual
Page 246
Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable. For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service.
http://www.auanet.org/practice-reso...resources-and-information/prostate-procedures
American Urological Association
Prostate Procedures
Q. Prior to transrectal guided prostate biopsy; my urologist performs a transrectal ultrasound to establish medical necessity to proceed with the prostate biopsy. The CPT® codes billed are transrectal diagnostic ultrasound (CPT® 76872), the sonographic guidance (76942) and prostate biopsy (55700). Some insurance companies are bundling the two ultrasound codes as incidental. Is there something we can do to convince carriers to pay these three codes?
A. Correct Coding Solutions, Medicare contractor for the National Correct Coding Initiative (NCCI), issued their final decision to bundle CPT code 76942 Ultrasonic guidance for needle placement paired with CPT codes describing diagnostic ultrasound procedures (specific for urology, CPT code 76872 Ultrasound, transrectal). Their decision was issued in a November 17, 2016 letter to the AUA after AUA questioned the contractor’s original edit that was implemented on July 1, 2016. The AUA also had participated on a conference call with the NCCI and Center for Medicare & Medicaid Services (CMS) representatives and requested that the edit be removed stating that these imaging procedures are performed for separate and specific reasons. The AUA believed that the edit would create erroneous denials.
However, after several attempts by the AUA to change the edit, CMS has updated the 2017 version of the National Correct Coding Initiative Policy Manual with the codes bundled. The following has been posted to the CMS NCCI website stating in Chapter 9 Radiology, Section H General Policy Statements, “Evaluation of an anatomic region and guidance for a needle placement procedure in that anatomic region by the same radiologic modality at the same or different patient encounter(s) on the same date of service are not separately reportable. For example, a physician should not report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement...) when performed in the same anatomic region on the same date of service. Physicians should not avoid these edits by requiring patients to have the procedures performed on different dates of service if historically the evaluation of the anatomic region and guidance for needle biopsy procedures were performed on the same date of service."
The AUA is recommending that providers should consider reporting either CPT code 76872 Ultrasound, transrectal; or CPT code 76942 Ultrasonic guidance for needle placement based on the procedure performed and the documentation in the patient’s chart. A modifier should not be used to unbundle this coding scenario as it has been deemed inappropriate coding.
CMS to Uphold Edit to Bundle Transrectal Ultrasound and Ultrasonic Guidance
By Policy and Advocacy Brief posted 12-07-2016 15:09
76942 billed with 76872
this billing is allowed by Medicare as long as you have documentation to support eh 76942, which includes either "Images were saved to the medical record" within the report or actually sending the images with the documentation you submit.
this billing is allowed by Medicare as long as you have documentation to support eh 76942, which includes either "Images were saved to the medical record" within the report or actually sending the images with the documentation you submit.
Do you have any documentation to support this is allowed by Medicare as the previous statement above per CMS NCCI edit manual says it is not allowed. If you have some written documentation I would love to have it as UHC Medicare is denying all claims with or without MOD 59 in this situation.