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Don't bill 59025, 76818 separately without separate physician orders

APCs Weekly Monitor, July 13, 2007

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QUESTION: We have a question about billing for fetal non-stress testing. A pregnant woman reports to labor and delivery where staff performs a non-stress test. The patient then reports to the radiology department where staff performs a fetal biophysical profile. Can we bill 59025 for the non-stress test and 76818 for the fetal biophysical profile without non-stress testing?

When we report both, a CCI edit occurs. Can we append modifier -59, or is this considered unbundling? If we can only bill 76819 (for a fetal biophysical profile with non-stress test), how would labor and delivery be able to bill for its services? This would mean that the revenue associated with 76819 would go to the ultrasound department.

ANSWER: The answer depends on the order(s) from the physician and the medical necessity of both tests. First of all, if the physician did not write an order, you cannot report a charge. If the physician only ordered the fetal biophysical profile (76818), or the non-stress test (59025), and the physician did not document a separate order for the second test, you cannot report both codes with modifier -59.

Good documentation criteria include specific orders for each test, which helps determine the medical necessity and appropriateness of appending modifier -59.  Also, if the order was just for the non-stress test (59025), and, after reviewing the results, the physician then orders a fetal biophysical profile, then there is good documentation to support appending modifier -59.

If the hospital has a practice or standing orders to allow physicians to always perform a non-stress test in advance of a fetal biophysical profile, you may not be able to report both codes with modifier -59, unless you have patient-specific signs/symptoms to warrant each test. A standing order or practice does not necessarily rise to the level of medical necessity for each patient. The fact that staff performed the two tests in two separate departments is also not enough basis to justify billing both tests, unless you have patient-specific medical necessity as documented through orders and signs or symptoms or diagnoses of the patient.

You can find additional information on billing these two codes together in the November 2004 CPT Assistant.

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