As noninvasive tests for assessing liver disease continue to evolve, it can be tempting to assume that technologies designed to assess the same clinical conditions are evaluated the same way by health plans.
Medical policies tell a different story.
BlueCross BlueShield of Tennessee’s (BCBSTN) recently updated medical policy for chronic liver disease continues to recognize transient elastography imaging (FibroScan®) as medically necessary for the evaluation and monitoring of chronic liver disease. The policy also states that other noninvasive imaging technologies that map the elastic properties of soft tissue are considered investigational and notes that evidence is currently insufficient to support certain alternative transient elastography techniques.
While technologies may appear similar from a clinical perspective, payer coverage decisions are made based on the evidence supporting each individual technology.
“The updated policy provides additional clarity for providers by distinguishing between noninvasive technologies that may appear similar but have different evidence bases and coverage determinations,” said Amy Conner, MPH, Director of Market Access and Pharma at Echosens, the manufacturer of FibroScan® and its VCTE® elastography system. “As new noninvasive tests enter the market, medical policies help clinicians understand which technologies have been evaluated and supported for specific clinical applications.”
Those distinctions have practical implications. A technology’s use of the same CPT code as a covered technology does not necessarily mean the payer considers the technology itself covered. Coverage is determined by the applicable medical policy, the supporting evidence and the services performed, not by the billing code alone.
Provider agreements generally require participating clinicians and health systems to follow payer medical policies. Billing for a technology that a payer considers investigational or non-covered under a code associated with a different, covered technology may create compliance and reimbursement risk. Depending on the payer agreement and circumstances, that could include payment recoupment, additional claims review or audit activity, and potential effects on the provider’s relationship with the health plan.
Coverage Is Only Part of the Story
Coverage policies, including the updated BCBSTN policy, recognize CPT code 76981 as appropriate for FibroScan® exams that include ultrasound image guidance, interpretation and documentation. That distinction is significant because the policy does not extend the same coverage determination to other elastography devices that may appear similar or use the same billing code.
FibroScan® also offers providers two coding options based on the specific work performed and documented during the examination.
“When billing for FibroScan® exams, I use CPT code 76981, which covers image guidance, interpretation and quality checking. Commercial payers, Medicare and Medicaid widely cover this code. If the report isn't saved or reviewed in detail, CPT code 91200 is appropriate,” said Martin Grajower, MD, endocrinologist.
For physicians who are new to FibroScan®, reimbursement can be relatively straightforward: code 76981 may be used when the exam includes ultrasound image guidance, image interpretation and documentation, while code 91200 may be appropriate when those additional services are not performed or documented.
Dr. Grajower’s approach reflects an important principle: CPT coding is based not only on the technology used, but also on the work performed, including image guidance, interpretation and documentation.
Matching the Code to the Work Performed
Providers performing exams may appropriately bill different CPT codes depending on the services performed during the examination.
“For physicians who are new to FibroScan®, I like to share that reimbursement is very straightforward. There are two appropriate CPT codes—76981 and 91200. Code 76981 is used when the exam includes ultrasound image guidance, image interpretation, and documentation. Code 91200 can be used if the exam report isn’t saved in the medical record, and/or the images are not reviewed,” said Bradley Anderson, MD, gastroenterologist.
Understanding those distinctions helps ensure that coding accurately reflects the examination performed while aligning with payer expectations.
The Takeaway
As new elastography technologies become available, providers should avoid assuming that similar technologies receive identical coverage determinations.
Instead, clinicians and health systems should review current payer medical policies, understand the evidence supporting individual technologies, and ensure that documentation and coding accurately reflect the work performed.
Ultimately, technology categories and regulatory bodies do not determine coverage. Medical policies do.
The editorial staff had no role in this post's creation.