Authorities scrutinize medical necessity for 76830 & 76856.
The OIG is watching your ultrasound orders and code combinations — and it doesn’t like what it sees. Take note of these problem spots to keep your claims in the clear.
An OIG audit of ultrasound services billed in 2007 found that nearly one in five ultrasound claims “had characteristics that raise concerns about whether the claims are appropriate,” according to a July 2009 audit report titled “Medicare Part B Billing for Ultrasound.”
The most common error: Roughly 17 percent of 2007 Part B ultrasound claims lacked prior service claims by the ordering physician, the OIG indicated.
What this means: Several physicians ordered ultrasounds for patients that they hadn’t treated within the last year. “The OIG would wonder why the doctor would order an ultrasound for a patient who [the ordering physician] hasn’t examined,” notes Allison Larro, Esq., an Atlanta-based attorney.
Another trouble spot: The OIG also focused on claims involving more than one ultrasound for the same patient on the same date. In particular, the OIG noted the following pairs:
• 76700 — Ultrasound, abdominal, real time with image documentation; complete
• 76705 — … limited (e.g., single organ, quadrant, follow-up).
• 76830 — Ultrasound, transvaginal
• 76856 — Ultrasound, pelvic (nonobstetric), real time with image documentation; complete.
• 93925 — Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study
• 93978 — Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study.
In the audit report, the OIG noted that it will “forward questionable claims identified by this report to its Recovery Audit Contractors [RACs] to consider in prioritizing areas for postpayment review.” And if RACs most likely will be looking carefully at ultrasound services in the coming months, you should, too.
US code example: If you report 76830 and 76856 on the same claim for the same patient, your documentation should support both exams fully, showing the medical necessity, results, and physician orders for both the pelvic and transvaginal scans.
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AUDIO TRAINING EVENT: Cheryl Schad reveals 5 characteristics that could make your ultrasound claims questionable in the OIG’s eyes.
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