April 19, 2018
Our sports medicine physicians are reporting diagnostic ultrasounds (76881) and ultrasound guided injections at the same session, same joint. We are receiving denials as inclusive and are not understanding why they are being denied.
Thanks for your inquiry. The ultrasound guided injections (20604, 20606 and 20611) include ultrasound image guidance in the definition of the code. These injections codes include the work associated with assessing the anatomic structures of the joint and the documentation of a separate report. Trying to report CPT code 76881 (Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time with image documentation) is inclusive to the work valued into the joint injection codes, hence the denial as inclusive.
This is also true of the use of ultrasound guidance with any other injection codes; the diagnostic component is inclusive to CPT code 76942 when this code may be reported with an appropriate injection code.
Medicare also considers the service to be inclusive.. The first reference is from the Medicare NCCI guidelines; the second notation is the introduction of new NCCI PTP edits effective April 1, 2018
Medicare NCCI guidelines also contain the following reference:
Section IX-H, Radiology Services – note: 2018 text revision highlighted in red
9. Evaluation of an anatomic region and guidance for a needle placement procedure by the same radiologic modality on the same date of service may be reported separately if the two procedures are performed in different anatomic regions. For example, a physician may report a diagnostic ultrasound CPT code and CPT code 76942 (ultrasonic guidance for needle placement…) when performed in different anatomic regions on the same date of service. Physician should not avoid edits based on this principle 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.
Additionally, effective April 1, 2018 , CMS NCCI implemented PTP edits between CPT codes 20604, 20606 and 20611 and 76881. CPT code 76881 is now identified a Column 2 PTP edit.
*This response is based on the best information available as of 04/19/18.