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:A

Policy #:00.03.10e

Description:High Risk Pregnancy

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 High Risk pregnancy obstetrical ultrasound is eligible for reimbursement to a participating perinatal or maternal fetal medicine specialist, (this includes certified registered nurse practitioners (CRNPS) and Physician Assistants (PAs) practicing within these specialty groups), are outlined below.

High Risk Pregnancy
Perinatal, Maternal Fetal Medicine
(Office and Hospital Outpatient Place of Service Only)
Procedure Code
76801
76802
76805
76810
76811
76812
76815
76816
76817
76818
76819
76820
76821

ICD-10 Code
O09.A0
O09.A1
O09.A2
O09.A3
O09.00
O09.01
O09.02
O09.03
O09.10
O09.11
O09.12
O09.13
O09.211
O09.212
O09.213
O09.219
O09.291
O09.292
O09.293
O09.299
O09.30
O09.31
O09.32
O09.33
O09.40
O09.41
O09.42
O09.43
O09.511
O09.512
O09.513
O09.519
O09.521
O09.522
O09.523
O09.529
O09.611
O09.612
O09.613
O09.619
O09.621
O09.622
O09.623
O09.629
O09.70
O09.71
O09.72
O09.73
O09.811
O09.812
O09.813
O09.819
O09.821
O09.822
O09.823
O09.829
O09.891
O09.892
O09.893
O09.899
O09.90
O09.91
O09.92
O09.93
O20.0
O36.80X0
O36.80X1
O36.80X2
O36.80X3
O36.80X4
O36.80X5
O36.80X9
O36.8310
O36.8311
O36.8312
O36.8313
O36.8314
O36.8315
O36.8319
O36.8320
O36.8321
O36.8322
O36.8323
O36.8324
O36.8325
O36.8329
O36.8330
O36.8331
O36.8332
O36.8333
O36.8334
O36.8335
O36.8339
O36.8390
O36.8391
O36.8392
O36.8393
O36.8394
O36.8395
O36.8399
Z03.71
Z03.72
Z03.73
Z03.74
Z03.75
Z03.79
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 High Risk pregnancy obstetrical ultrasound is eligible for reimbursement to the Outpatient Hospital are outlined below.

Procedure Code
76801
76802
76805
76810
76811
76812
76815
76816
76817
76818
76819
76820
76821

ICD-10 Code
O09.A0
O09.A1
O09.A2
O09.A3
O09.00
O09.01
O09.02
O09.03
O09.10
O09.11
O09.12
O09.13
O09.211
O09.212
O09.213
O09.219
O09.291
O09.292
O09.293
O09.299
O09.30
O09.31
O09.32
O09.33
O09.40
O09.41
O09.42
O09.43
O09.511
O09.512
O09.513
O09.519
O09.521
O09.522
O09.523
O09.529
O09.611
O09.612
O09.613
O09.619
O09.621
O09.622
O09.623
O09.629
O09.70
O09.71
O09.72
O09.73
O09.811
O09.812
O09.813
O09.819
O09.821
O09.822
O09.823
O09.829
O09.891
O09.892
O09.893
O09.899
O09.90
O09.91
O09.92
O09.93
O20.0
O36.80X0
O36.80X1
O36.80X2
O36.80X3
O36.80X4
O36.80X5
O36.80X9
O36.8310
O36.8311
O36.8312
O36.8313
O36.8314
O36.8315
O36.8319
O36.8320
O36.8321
O36.8322
O36.8323
O36.8324
O36.8325
O36.8329
O36.8330
O36.8331
O36.8332
O36.8333
O36.8334
O36.8335
O36.8339
O36.8390
O36.8391
O36.8392
O36.8393
O36.8394
O36.8395
O36.8399
Z03.71
Z03.72
Z03.73
Z03.74
Z03.75
Z03.79
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



2017 AmeriHealth.