Medical Billing Forum
Coding => Coding => : AKA October 18, 2018, 02:21:04 PM
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Anyone familiar with physical therapists billing CPT code 76881? I'm working with a PT who is certified with ultra sound diagnostic and he billed CPT code 76881 for 2 units with diagnosis codes S43.51XA & S43.52XS. The claim was denied with reason code PR-172.
Is there a modifier that should be included? Should the specialty be different? Does it have to do with the taxonomy code the therapist is under?
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What insurance is it? The denial code indicates that the insurance carrier does not recognize the provider as being able to perform that service. It may be that they don't allow PTs to do ultrasound, even if the PT is certified, or it may be that they don't have it indicated on their records that they are certified. Either way, you need to contact the insurance to find out if they do indeed allow a PT who is certified to be reimbursed for ultrasound.
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Its Horizon NJDirect. I called and they said PT's aren't listed to bill for this code but we do know that other PTs in the area perform ultra sound diagnostic and are getting reimbursed. Just wondering if those other providers bill under a different specialty or if there's a different code.
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Does Horizon NJDirect have a provider rep for your area? They may be able to help you. It sounds like it may be the way the PT is set up in the system.
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It sounds like a taxonomy issue. I too agree with Michele to see if you can get a provider rep to help you. What you def don't want to do is tell them "We know other providers who get reimbursed by you for this" due to non disclosures in their contracts. You simply tell them you have been researching and reviewing your contract and can't see where this service cannot be provided by the PT. It really does sound like it has something to do with the taxonomy being used.