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?
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.