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(2022) CPT Code 76942 – Description, Guidelines, Reimbursement, Modifiers & Example

CPT code 76942 describes the ultrasound guidance for major or minor surgical procedures like breast nodule biopsies, aspiration, and localising device placement.

With the help of ultrasound guidance, the provider can introduce the needle inside the body to reach the specific tissue or target site. In addition, it helps in performing tissue biopsy or aspiration.

The exclusive practice of this method provides the surgeon the flexibility to execute the surgical procedure without damaging any of the nearby tissues or organs.

76942 CPT Code Description

CPT code 76942 is ultrasonic supervision that is used as an add-on service. This code is used for for guiding needle placement required for procedures such as injections, breast biopsies, placing localising devices or needle aspirations. 

76942 CPT Code Description
76942 CPT Code Description

The sound waves pass through different tissue densities and reflect a receiving unit at varying speeds. The unit converts the waves to electrical pulses immediately displayed in picture form on the screen.

The ideal route is evaluated, from the surface to the marked tissue, as soon as the precise access site for the needle is sited, accompanied by the deepness of the target tissue. Then the needle is inserted and advanced to the lesion under ultrasonic supervision.

Sound waves of higher frequencies are used by Ultrasonography (above the standard hearing capacity of a healthy human, i.e., 20,000 Hz or 20 kHz) to visualize the body’s internal organs. 

Sound waves are reflected at different speeds by the different types of tissues, e.g., bones, muscles, etc. when a sound wave pass through the human body.

These rebounding waves are captured by the detector and converted into images. While carrying out the surgical procedure, such as a needle biopsy, the provider needs to have diagnostic guidance to identify the exact location to be biopsied to carry out the accurate placement of the needle in that region.

With the help of the Ultrasound guidance (76942 CPT Code) technique, the provider can perform the major or minor surgical procedures specific to the targeted anatomic region of the human body. In addition, several different invasive procedures are accomplished with the help of ultrasound direction.

Note: CPT code 76942 reports the imaging supervision and interpretation only for the specific procedure.

The 76942 CPT Code belongs to the category of IR (interventional Radiology) procedure. Interventional Radiology is the process when a provider performs ultrasound or fluoroscopic procedures to get images of the inside of the body. IR (Interventional Radiology) procedure (CPT 76942) permits two crucial things at once. 

The first one is that the surgeon gets direct access to the part of the body that needs some interventions to get treated or diagnosed. 

At the same time, the second one prevents any injury to the adjacent tissues from the risky tissue.

Coding Guidelines For The 76942 CPT Code

CPT code 76942 is mainly used for percutaneous procedures. Percutaneous surgeries are the same day and minimally invasive surgical procedures having 0 days global period. The 76942 CPT code is used as a diagnostic ultrasound for non-vascular procedures.

That means, if a surgeon wants to access any bone joints or muscular structure for any intervention, he may get the help of ultrasound imaging to prevent the adjacent tissue damage.

As per the guidelines, MUE (medically unlikely edits) adjudication indicator for CPT 76942 is represented as three dates of service (DOS), and 1 unit is allowed to bill for one provider on the same date of service (DOS) under a single NPI (National Provider Identifier). But several units of CPT code 76942, more than one can be billed, and it depends on diverse circumstances.

CPT code 76942 was introduced on 1st January 1993 and updated on 1st January 2001.

Note: Ultrasound guidance CPT 76942 has zero global periods.

While coding or billing, one should keep in mind that the fundamental difference between below mentioned ultrasound guidance studies is to comprehend the selection of accurate CPT and appropriate reimbursements. CPT 76942 and CPT 76937 are both used for ultrasound guidance. But the 76942 CPT code is used as ultrasound guidance for non-vascular access, and CPT 76937 is used as ultrasound guidance for vascular access.

In interventional radiology (IR), if ultrasound supervision is carried out for the vascular procedure, the coder or biller may use the CPT 76937. Some of the common examples are central venous catheter placement and angioplasty. While coding the CPT 76942, a few main normalities should be followed in documentation; the potency of the blood vessel, recording of the image, and under ultrasound guidance documentation. 

The examples for CPT code 76942, ultrasound guidance non-vascular procedures, are arthrogram, arthrocentesis, biopsy, etc., where the target site is not a vessel.

Incorrect selection of CPT may lead to denials because the 76942 CPT code is an add-on CPT code and can be billed only with a parent CPT code. There are only a few definite CPT codes that are considered parent CPT codes while billing CPT 76942. The selection of an inappropriate code may affect the claims FPR, which may affect the revenue cycle of the practice.

CPT code 76942 acts as an add-on service code and cannot be reported with several other procedures that are also used as an add-on service. Some examples are CPT 10004, CPT 10005 CPT & 10006, CPT 32554, CPT CPT 32555, CPT 32556, and CPT 32557.

The coder or biller should pay close attention to the description and avoid reporting the 76942 CPT code with those primary procedures that already include imaging guidance. 

For example, in the case of CPT 20611: It is a primary procedure and is considered a parent CPT. Furthermore, as per the description, CPT 20611 includes any type of imaging guidance. Thus, CPT 20611 is billed alone as a single line item and cannot be reported, in any way, with CPT 76942.

76942 CPT Code Reimbursement

The billing guidelines and reimbursement policy for CPT code 76942 are governed by appropriate usage of Modifiers, Place of services (POS), and medical necessity as per the stated local coverage determination (LCD).

Both government (Medicaid or Medicare) and commercial payers have similar rules and policies for this procedure (CPT 76942). Therefore, the health provider office must adequately document the ultrasound guidance procedure (CPT 76942) and the primary procedure that may act as principal service in the claim.

If the 76942 CPT code is not covered by any payer, ABN (Advance Beneficiary Notice) must be presented to the patient before providing the service. If the payer (insurance company) denies the service at later stages, it can be billed and get reimbursed from the patient.

Ultrasound guidance procedure (CPT 76942) should be billed at the secondary position as the second line item in a claim. The primary CPT code in the claim must always be the surgery procedure code followed by the US guidance CPT code 76942. 

Mainly with the major procedures, the 76942 CPT code is considered a bundled service, such as breast biopsy and spinal injection procedure.

CPT code 76942 is used only once in the same encounter, even if two or more lesions are needle biopsied at the same time. For Commercial insurances, the provider must confirm individual payer policies against several units allowed per date of service (DOS). 

Most commercial payers allowed only one-time usage of this CPT in an encounter. Therefore, do not use laterality modifiers or anatomical modifiers like LT, RT, and 50 with CPT 76942. Laterality modifiers are not eligible with CPT code 76942.

Note: 76942 needs a separate report (not part of the primary procedure notes) to fulfill the radiology documentation requirements. Sometimes, payers make it obligatory to submit complete documentation for the procedure.

While coding IR (interventional radiology) procedures, selecting the correct code is essential because reimbursement is highly dependent on code selection. The fee for service (FFS) comparison between CPT 76942 and CPT 76937 is about $19.

CPT 76937: The Fee for Service (FFS) for the facility and non-facility is $40.49.

CPT 76942: The Fee for Service (FFS) for the facility and non-facility is $59.52.

CPT Code 76942 Modifier 26, LT, RT & 50

The usage of modifiers with CPT code 76942 can only be made if a procedure has been reformed or changed, or renewed by some definite conditions but has not been altered in its concrete description.

CPT Code 76942 Modifier
CPT Code 76942 Modifier

While claim submission, the appropriate placement of a modifier plays a key role. As per CMS rule, the pricing modifier should be placed first, then statistical or payment eligible modifier, and in the last laterality modifier. 

Laterality modifiers are also called anatomical modifiers such as LT, RT, and 50. Laterality or anatomical modifiers are not valid and are not required to be billed with CPT 76942.

CPT code 76942 has professional and technical components included in its RVU (Relative Value Unit) package. 

The technical component of the 76942 CPT code is the performance of the test by the technician.

While the professional component of CPT code 76942 is interpreting the test and preparing a detailed report.

Both parts of this procedure can be represented and billed separately. If a hospital or provider requires to bill this for a technician, then it is billed under technician NPI (National Provider identifier) with modifier TC.

If a provider delivers only professional services and requires to bill this for a physician, then it is billed under physician NPI (National Provider Identifier) with modifier 26.

Neither modifier TC nor modifier 26 are required for billing these services globally. The coder or biller can bill this procedure (CPT 76942) without modifiers, and the benefits of both components (technical and professional) may be included in the single line item.

The provider may not submit CPT code 76942 globally to commercial or private payers when ultrasound guidance the 76942 CPT code is performed as an add-on service with any other principal procedure in Hospital outpatient or ASC (Ambulatory surgery center) settings because the hospital may bill for the technical component of the procedure. 

CPT 76942 may be billed with a professional component (modifier 26) for the radiologist In the setting mentioned above. 

For trigger point injections, when two different sites are approached on the same date of service (DOS), e.g., the trapezius muscle and the gluteus muscle, are injected for pain management on the same day, then it may be billed with the CPT code 76942 twice.

Because the access sites are in different body regions. In such circumstances, the coder or biller must use eligible payment modifiers to notify the insurance that the service was necessary to perform repeatedly. 

The coder may use the modifier XS to present that the service was performed on a different structure for Medicare. While for commercial insurances, one may use the modifier 59 for the same purpose.

Although, as per CMS released guidelines and data, there is no CCI conflict even billed twice in separate line items.

On the other hand, if the trigger point is in the same region like trapezius and posterior cervical, then only one unit may be billed because the site of body or structure on which the procedure is performed is the same.

In the surgical post-operative Global period, one may have to use modifier 79 to notify the payers that service is not performed as a part of previous services to the same patient. It has a global period of 10 days in case of minor surgery and 90 days in major surgery.

Billing Example For CPT Code 76942

A 65-year-old patient came to the provider in an outpatient hospital setting with a lab report of an elevated PSA, hematuria, and urinary incontinence (prostate-specific antigen) having a value greater than 4.0 ng/ml. 

After physical examination, the physician decided to do a prostate biopsy with ultrasound guidance procedure to rule out any malignancy. A patient already has a high PSA level and prostate enlargement.

In the above case, needle or punch prostate biopsy single or multiple (CPT 55700) was performed with the help of ultrasound guidance (CPT code 76942).

The provider may be taking several tissue samples from the prostate repeatedly to minimise the chance of missing an area where cancer may be present.

But the ultrasound guidance as per the guidelines can only be billed once in a separate line item on a single date of service (DOS).

Then the samples are sent to a pathology lab for confirmatory diagnosis.

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