Radiology Question for the Week of May 7, 2018

Question:

I have a follow-up question regarding the instructions given in the April 23 radiology question for the venous duplex scans of both the upper and lower extremities. The instructions were to add modifier -59 to the second 93970 to indicate that it was a different body area. This follows standard coding guidelines; however, we received a denial from our MAC (WPS or NGS) indicating we were to use modifier -76 based on CMS Transmittal 1702 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1702CP.pdf) which states:

For only those instances that involve more than one bilateral procedure and are medically necessary and appropriate, hospitals are advised to report the procedure code with a modifier -76 (repeat procedure or service by same physician) in order for the claim to process correctly. Appending modifier -76 to one of the reported bilateral HCPCS code indicates that the bilateral procedure or service was repeated on the same day for the same patient.

Is this information still applicable?

Answer:

The answer to the April 23 question (to use modifier 59) was based on guidelines published by the American Medical Association (AMA); however, each payer can make and require their own rules. When that happens, you must follow the rules for your payer.

In the case of modifier -76, some payers such as your MAC use the same CPT code as the basis of “repeat exam,” while others say that before -76 can be used the exact same procedure on the exact same body part must be repeated.

If your MAC has said to use modifier -76 when arm(s) and leg(s) are evaluated with non-invasive exams, then that is what you should do.