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:D

Policy #:00.03.10e

Description:First-trimester screening and Ovarian Dysfunction

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 an ovarian dysfunction ultrasound is eligible for reimbursement to a participating Reproductive Endocrinology specialist, (this includes certified registered nurse practitioners (CRNPS) and Physician Assistants (PAs) practicing within these specialty groups), within the scope of their specialty) are outlined below.

Ovarian Dysfunction
Reproductive Endocrinology
(Office Place of Service Only)
Procedure Code
76830
76857

ICD-10 Code
E28.1
E28.8
E28.9
N97.9
N98.1


The circumstances for which a First trimester screening 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.

First Trimester Screening
Maternal Fetal Medicine
(Office Only)
Procedure Code
Modifier
76801
76802
when billed in conjunction with:
76813
76814
ICD-10 Code
Z36.0
Z36.1
Z36.2
Z36.3
Z36.4
Z36.5
Z36.81
Z36.82
Z36.83
Z36.84
Z36.85
Z36.86
Z36.87
Z36.88
Z36.89
Z36.8A
Z36.9

First Trimester Screening
Maternal Fetal Medicine
(Hospital Outpatient Place of Service Only)
Procedure Code
Modifier
76801
26
76802
26
when billed in conjunction with:
76813
26
76814
26

ICD-10 Code
Z36.0
Z36.1
Z36.2
Z36.3
Z36.4
Z36.5
Z36.81
Z36.82
Z36.83
Z36.84
Z36.85
Z36.86
Z36.87
Z36.88
Z36.89
Z36.8A
Z36.9

Outpatient Hospitals

The circumstances for which a First trimester screening obstetrical ultrasound is eligible for reimbursement to the Outpatient Hospital are outlined below.

Procedure Code
76801
76802
when billed in conjunction with:
76813
76814

ICD-10 Code
Z36.0
Z36.1
Z36.2
Z36.3
Z36.4
Z36.5
Z36.81
Z36.82
Z36.83
Z36.84
Z36.85
Z36.86
Z36.87
Z36.88
Z36.89
Z36.8A
Z36.9


Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A



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