Coding and modifiers for biophysical profiles performed on triplets
What would be the correct charges for CPT® code 76819 (biophysical profile) if performed for triplets? I know the MUE is 2. What modifiers would be appropriate? Some guidelines state 59, and some state XE. If a second set of code 76819 is performed later in the day, are they reportable? (This would make for 76819 x 6 for 1 date of service.) If so, what modifiers would be appropriate?
Because modifier XE indicates a “separate encounter,” XE would not be appropriate when the exams are performed for triplets at the same session. If you repeat the biophysical profile (BPP) later in the day, then modifier XE would be appropriate.
The MUE for code 76819 is 2, but the MAI is 3, which means that the contractor can override the MUE and reimburse for more if medically necessary. If you have triplets, that would be medically necessary, and you should include a diagnosis code that indicates triplets (i.e., O30.10-). Whether the insurance will pay for two sets of BPP depends on the individual plan’s policy and the medical necessity for repeating the BPP.
There are different guidelines because the X modifiers were created by Medicare, so guidelines from the AMA would not use X modifiers but would use modifier 59. And modifier use is not standardized between payors, so which modifiers you use is dependent on the payor’s modifier policy. Some payors may even want modifier 76 instead of 59.
One possible way to code would be:
If repeated later the same day:
76819-76 (or 77 if another doctor does it or interprets the study)
76819-76-XE or XS
The code and full description are as follows:
76819 Fetal biophysical profile; without non-stress testing