AmyW_37625
New member
Can you code 76881 for an Orthopedic PA that does an Ultrasound? It’s a mobile Ultrasound he has in his office. He interprets the ultrasound as well.
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Resolved PA Performing Ultrasound
- Thread starter AmyW_37625
- Start date
Lori
Well-known member
Coding Guidance
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Per CPT guidelines, "Code 76881 represents a complete evaluation of a specific joint in an extremity. Code 76881 requires ultrasound examination of all of the following joint elements: joint space (e.g., effusion), peri-articular soft-tissue structures that surround the joint (i.e., muscles, tendons, or other soft tissue structures), and any identifiable abnormality. In some circumstances, additional evaluations such as dynamic imaging or stress maneuvers may be performed as part of the complete evaluation. Code 76881 also requires permanently recorded images and a written report containing a description of each of the required elements or reason that an element(s) could not be visualized (e.g., absent secondary to surgery or trauma).
When fewer than all of the required elements for a ‘complete’ exam (76881) are performed, report the ‘limited’ code (76882)."
According to CPT guidelines, “Code 76882 represents a limited evaluation of a joint or a focal evaluation of a structure(s) in an extremity other than a joint (e.g., soft-tissue mass, fluid collection, or nerve). Limited evaluation of a joint includes assessment of a specific anatomic structure(s) (e.g., joint space only [effusion] or tendon, muscle, and/or other soft tissue structure that surround the joint) that does not assess all of the required elements included in 76881. Codes 76882 and 76883 also require permanently recorded images and a written report containing a description of each of the elements evaluated.”
Documentation must support the right (RT), left (LT), or digit modifiers, as reported.
If less than the required elements for a "complete" exam are reported (e.g., limited number of organs or limited portion of region evaluated), the "limited" code for that anatomic region should be used once per patient exam session.
A "limited" exam of an anatomic region should not be reported for the same exam session as a "complete" exam of that same region.
Professional Component (PC) and Technical Component (TC)
Ultrasound codes are combined, or "global," service codes that include both the TC and the PC. In the emergency department setting, the hospital will typically report the TC that covers the cost of equipment, supplies, and personnel necessary for performing the service. The PC is reported by the physician for the interpretation of the ultrasound and documentation of the results.
CMS defines hospital-based emergency departments (EDs) as "facilities" and requires radiology CPT codes to be divided into professional and TC.
Use of Modifier-26:
If the site of service is the hospital, the –26 modifier, indicating only professional service was provided, must be added by the physician to the CPT code for the ultrasound service.
www.cms.gov
There are 3 basic types of reimbursement that Medicare provides for these non-physician providers (NPPs).
By filing a claim “Incident to”, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85% of the MPFS for care provided by a qualified NPP. New patients should be seen by the physician to set up the Plan of Care and this would be billed under the rendering physician. After the initial visit, the NPP can provide follow-up care based on the Plan of Care, billing for direct care as “Incident to”. If adjustments are made to the plan of care such as medication changes, then the physician should see the patient face to face in order to adjust the original plan of care, otherwise, the visit may not qualify for “Incident to” billing.
“Incident to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, therefore knowing payer regulations regarding “Incident-to” billing is imperative prior to providing patient care.
Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate. As long as the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.
Documentation is paramount in this type of billing. Each practitioner must thoroughly document the care they provided to substantiate reimbursement under the split/share guidelines allowing both parties to bill for care.
According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services rendered in the following settings:
capturebilling.com
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Per CPT guidelines, "Code 76881 represents a complete evaluation of a specific joint in an extremity. Code 76881 requires ultrasound examination of all of the following joint elements: joint space (e.g., effusion), peri-articular soft-tissue structures that surround the joint (i.e., muscles, tendons, or other soft tissue structures), and any identifiable abnormality. In some circumstances, additional evaluations such as dynamic imaging or stress maneuvers may be performed as part of the complete evaluation. Code 76881 also requires permanently recorded images and a written report containing a description of each of the required elements or reason that an element(s) could not be visualized (e.g., absent secondary to surgery or trauma).
When fewer than all of the required elements for a ‘complete’ exam (76881) are performed, report the ‘limited’ code (76882)."
According to CPT guidelines, “Code 76882 represents a limited evaluation of a joint or a focal evaluation of a structure(s) in an extremity other than a joint (e.g., soft-tissue mass, fluid collection, or nerve
Documentation must support the right (RT), left (LT), or digit modifiers, as reported.
If less than the required elements for a "complete" exam are reported (e.g., limited number of organs or limited portion of region evaluated), the "limited" code for that anatomic region should be used once per patient exam session.
A "limited" exam of an anatomic region should not be reported for the same exam session as a "complete" exam of that same region.
Professional Component (PC) and Technical Component (TC)
Ultrasound codes are combined, or "global," service codes that include both the TC and the PC. In the emergency department setting, the hospital will typically report the TC that covers the cost of equipment, supplies, and personnel necessary for performing the service. The PC is reported by the physician for the interpretation of the ultrasound and documentation of the results.
CMS defines hospital-based emergency departments (EDs) as "facilities" and requires radiology CPT codes to be divided into professional and TC.
Use of Modifier-26:
If the site of service is the hospital, the –26 modifier, indicating only professional service was provided, must be added by the physician to the CPT code for the ultrasound service.
Article - Billing and Coding: Non-Vascular Extremity Ultrasound (A55037)
Use this page to view details for the Local Coverage Article for billing and coding: non-vascular extremity ultrasound.
www.cms.gov
There are 3 basic types of reimbursement that Medicare provides for these non-physician providers (NPPs).
Direct Pay
Direct pay is when the NPP holds their own Provider Identification Number (PIN). This reimburses the NPP (or practice) at 85% of the billable physician rate. It is very important that each of your mid-level providers receives his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN number, if possible, based on payer rules and regulations. However, many payers will not credential NPPs. Having the NPP credentialed allows practices to bill insurance companies directly when the “supervising physician” is either not on site or has not provided any care or input into patient’s plan of care.“Incident to”
“Incident to” billing is a way of billing outpatient services rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home provided by a non-physician practitioner (NPP). With incident to billing, the physician bills and collects 100% of Medicare’s allowable reimbursement. This type of billing is used when an NPP sees a patient in which the physician has performed the initial service and has initiated a Plan of Care or treatment plan. There are specific rules for this type of billing, the physician must be on site, in the suite, not just in the building, and provides direct supervision (the rules for home visits varies).By filing a claim “Incident to”, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85% of the MPFS for care provided by a qualified NPP. New patients should be seen by the physician to set up the Plan of Care and this would be billed under the rendering physician. After the initial visit, the NPP can provide follow-up care based on the Plan of Care, billing for direct care as “Incident to”. If adjustments are made to the plan of care such as medication changes, then the physician should see the patient face to face in order to adjust the original plan of care, otherwise, the visit may not qualify for “Incident to” billing.
“Incident to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, therefore knowing payer regulations regarding “Incident-to” billing is imperative prior to providing patient care.
Split/Shared Expenses
Split/shared expenses: “A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate. As long as the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.
Documentation is paramount in this type of billing. Each practitioner must thoroughly document the care they provided to substantiate reimbursement under the split/share guidelines allowing both parties to bill for care.
According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services rendered in the following settings:
- Hospital inpatient or outpatient
- Emergency department
- Hospital observation
- Hospital discharge
- Office or clinic (when “incident-to” requirement are met)
- In a skilled nursing facility or nursing facility setting
- For consultation services
- For critical care services
- For procedures
- In a patient’s home or domiciliary site
Coding and Billing for NP and PA Providers in Your Medical Practice
Understanding how to properly bill and code for services provided by NPPs is imperative to running a cost-effective and efficient medical practice. See how.
capturebilling.com