Coding and submission considerations when outside provider provides fine-needle aspiration guidance

Q.

The question was raised if one of our doctors provides ultrasound guidance for a provider from outside our group who performs a Fine Needle Aspiration (FNA), can we assign CPT^® code 76942?

A.

The first step is to verify that your radiologist knows that the FNA code includes guidance and, if this comes up again, they should either do the FNA themself, or let the other doctor perform the guidance. Most believe that this is not a 2-person job.

Based upon recent recommendations from the American Medical Association (AMA) concerning CPT code 96450, where the same thing happens frequently, both doctors would assign CPT code 10005–52. If both doctors submit CPT code 10005–52, what should happen is that each would get 1/2 of the payment. What probably will happen though is that the first one to get their claim in will get paid and the other will be denied (already paid to another provider), and you’d have to go through rounds of appeals and still may or may not receive reimbursement.

If the other provider billed CPT code 10005 without modifier 52, then you’ll have even more of a problem. Did your doctor dictate a report describing the US guidance? (not just that ultrasound was provided to Dr. X)?  If not, they can’t bill at all. According to the CPT book, there must be permanent imaging and a description of the guidance procedure in the medical record.