Notification

Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product


Notification Issue Date: 11/01/2017



Policy Attachment



Attachment to Policy # 00.03.10e


Attachment:C

Policy #:00.03.10e

Description:Rule out intrauterine pathology and Screening for Fetal abnormalities

Title:Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



In certain circumstances, medically necessary obstetrical ultrasound services are eligible for reimbursement by the Company to participating providers or hospitals at a non-capitated site.

Specialists

The circumstances for which a Rule Out Intrauterine Pathology obstetrical ultrasound is eligible for reimbursement to a participating Obstetrics-Gynecology or Reproductive Endocrinology specialist, (this includes certified registered nurse practitioners (CRNPS) and Physician Assistants (PAs) practicing within these specialty groups), are outlined below.

Rule Out Intrauterine Pathology
Obstetrics-Gynecology, Reproductive Endocrinology
(Office Only)
Procedure Code
Modifier
76831
Rule Out Intrauterine Pathology
Obstetrics-Gynecology, Reproductive Endocrinology
(Hospital Outpatient Place of Service Only)
Procedure Code
Modifier
76831
26

The circumstances for which a Screening for Fetal Abnormalities obstetrical ultrasound is eligible for reimbursement to a participating maternal fetal medicine specialist, (this includes CRNPS and PAs practicing within these specialty groups), are outlined below.

Screening for Fetal Abnormalities
Maternal Fetal Medicine
(Office Only)
Procedure Code
Modifier
76805
76810
76813
76814
76825
76826
76827
76828
Screening for Fetal Abnormalities
Maternal Fetal Medicine
(Hospital Outpatient Place of Service Only)
Procedure Code
Modifier
76805
26
76810
26
76813
26
76814
26
76825
26
76826
26
76827
26
76828
26


Outpatient Hospitals

The circumstances for which a Screening for Fetal Abnormalities obstetrical ultrasound is eligible for reimbursement to the Outpatient Hospital are outlined below.

Procedure Code
Modifier
76805
76810
76813
76814
76825
76826
76827
76828
Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A



2017 AmeriHealth.