When performed in a hospital setting for ventilated patients in the ICU or for Operative patients with a need for ultrasound diagnostic procedures, the professional service only are separately payable when billing using Procedure code 76999 with the modifier 26 to show professional component.
When we billing the claim as globally in hospital setting with code 76999, will be returned as unprocessable to the provider with a reason code such as 59 denotes “Payment adjusted because treatment was deemed by the payer to have been rendered in an appropriate or invalid place of service.”
When service are billed in a hospital setting as technical services with the code 7699-TC, Medicare will denied the claim as reason code 58 and Remark code M77 “Missing/Incomplete/Invalid place of service.”
When performed in an ambulatory surgery center (ASC), ultrasound diagnostic procedures are covered when performed by and entity other than the ASC if globally billed using 7699-TC and 76999-26 respectively.
Ultrasound diagnostic procedure progessional services billed using codes 76999, 76999-TC, 76999-26 are carried-priced.
Medicare carriers have been made aware that claims will be made and makes it clear that such claims have to be paid, although the level of payment is left to the carrier to determine. The use of an unlisted procedure code (76999) is unusual and may make the initial claims process a little more complicated than is normally the case. However, CMS has instructed carriers to pay claims for physician services with respect to EDM under this code and for that reason 76999 is as valid as any other Procedure code.
How should the level of service be quantified?
CMS has not specified how to report the use of EDM in either the ICU or surgical setting. One option for billing the service is to claim one occurrence of 76999 each time a patient is hemodynamically assessed and optimized using EDM. For each optimization ‘cycle’ the physician is required to place and focus the esophageal probe, establish a base-line value for key hemodynamic parameters (for billing purposes ‘stroke volume’ should suffice) and then deliver serial boluses of intravenous fluid until the stroke volume value change is less than ten percent, indicating that the patient is optimized. A subsequent fall in stroke volume of greater than ten percent would trigger the next optimization cycle and a further claim under 76999. This approach may be used for patients in surgery or ICU.
How will claims for the use of EDM be processed?
The use of a miscellaneous code such as 76999 requires that the claim be manually processed. This will probably require a response to requests for supplemental information the first claims submitted.