Ultrasound, pelvic (nonobstetric), CPT® 76856 - Targeted Probe and Educate Review Results - JE Part B
Ultrasound, pelvic (nonobstetric), CPT® 76856 - Targeted Probe and Educate Review Results
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for 76856, Ultrasound, pelvic (nonobstetric), real time with image documentation; complete. The results of this focused review are not a reflection on providers’ competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation.
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 76856 - Ultrasound, pelvic (nonobstetric), real time with image documentation; complete. The quarterly edit effectiveness results from October 1, 2023, through December 31, 2023, are as follows:
Top Denial Reasons
- Failure to return records.
- The documentation submitted does not support medical necessity.
- The documentation submitted was incomplete and/or insufficient.
Educational Resources
Education
Failure To Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/Or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).
Complete Pelvic Ultrasound, CPT® 76856
The complete pelvic ultrasound is a diagnostic procedure using sound waves to create a video image of the pelvis. CPT® Code 76856 constitutes a complete exam when the following elements are evaluated: description and measurement of uterus, adnexal, endometrium, bladder (when applicable), and description of any pelvic findings. This code would also be reported for a complete male pelvic exam when the following elements are evaluated: examination and measurement (when applicable) of urinary bladder, prostate, and seminal vesicles as visualized transabdominally, and any pelvic findings.
Ensure that the documentation supports the indication for the complete pelvic ultrasound and how it is going to be used in the treatment of the patient.
For additional educational resources, please visit our Education and Outreach department.
