For commercials we bill CPT 76856 Ultrasound Pelvic Complete and 76830 Transvaginal get paid for is denied as included in primary procedure. How to handle this?

When it comes to medical billing, there are certain rules and guidelines that must be followed to ensure accurate and compliant claims. In the case of CPT codes 76856 (Ultrasound Pelvic Complete) and 76830 (Transvaginal), it is possible that the latter may be denied as included in the primary procedure. Here are a few steps you can take to handle this situation:

1. Review the Payer's Policy:

- Start by thoroughly reviewing the specific payer's policy regarding the billing of CPT codes 76856 and 76830. Each payer may have different rules, so it's essential to understand their guidelines to determine if the denial is justified.

2. Check Medical Necessity:

- Ensure that the medical necessity for both CPT codes is well-documented in the patient's medical records. The treating physician should clearly indicate why both procedures were necessary and how they contributed to the patient's diagnosis or treatment.

3. Modifier Usage:

- If the payer's policy allows, you may consider using appropriate modifiers to indicate that the procedures were performed independently and for separate medical reasons. For example, you could use modifier 59 (Distinct Procedural Service) with CPT code 76830 to signify that it was a separate and distinct procedure from the complete pelvic ultrasound.

4. Appeal the Denial:

- If you believe the denial is incorrect or unjustified, you have the right to appeal the decision with the payer. The appeal process typically involves submitting additional documentation, such as medical records, operative notes, and any supporting evidence that demonstrates the necessity of both procedures.

5. Consider Rebilling:

- If the appeal process is unsuccessful, you may consider rebilling the claim with more specific and detailed information to clarify the medical necessity of both CPT codes. This might involve providing more detailed descriptions of the procedures and how they were performed.

6. Communication with the Payer:

- Establishing open lines of communication with the payer can be helpful in understanding their policies and guidelines. You may contact their customer service or provider relations department to discuss the denial and seek clarification on their billing requirements.

7. Stay Up-to-Date with Billing Guidelines:

- Medical billing guidelines and payer policies are subject to change, so it's important to stay updated with the latest information. Regular monitoring of payer websites, subscribing to billing newsletters, or attending billing workshops can help you stay informed about any changes that may affect your billing practices.

By carefully reviewing the payer's policy, checking medical necessity, exploring modifier usage, and appealing the denial if necessary, you can effectively address the issue of CPT code 76830 being denied as included in the primary procedure. Proper documentation and adherence to billing guidelines are key to ensuring accurate and successful reimbursement for your services.