aium communities

Every ultrasound specialty. One professional network.

I am currently in a dispute with my insurance company (Aetna) over covering my 20 week ultrasound. The biller that my OB uses says that in their opinion what they did falls under the CPT code 76811, but my insurance company says it is 76805 therefore will not cover my 20 week ultrasound. When my ultrasound tech performed the ultrasound they examined the head, face and neck, the chest (all the chambers of the heart), abdomen along with all the abdominal organs and umbilical cord insertion site into the fetal abdomen), spine, extremities and sex (only because it was readily visible). Who is right? And where can I go to back up my case against the incorrect party. The biller did send me a copy of the CPT code book and there is no description in the book that details what exactly the CPT code 76805 does, like what 76811 does.  I have looked up some things online and have found some statements that 76811 is only used for high risk pregnancies or when there is an anomaly found during the routine ultrasound.  Neither of which applied to me. What do I do? Please help!!

Views: 6599

Replies to This Discussion

Laura...

We have currently been in a major discussion about this recently in our facility, in fact this is the main reason I joined this group. In your case I think Aetna is right. At our facility in WA state, we have always performed ALL of the elements contained in a 76811 and thought that we were coding and billing for that routinely, but have found out that many were only being down coded as a 76805 because of the missing "high-risk" link. I have a copy of the ACR (American College of Radiology) Ultrasound Coding book and it does state clearly that the 76811 is only used for high-risk, however, the problem as we see it is that there is NO clear definition by the ACR of what that is. There is a very broad definition of this depending on who you ask. My suggestion to you would be to contact the billing office of the Imaging Dept that did your exam and ask them to down code it to a 76805 or tell you what "they" consider high risk. If this fails to work, maybe ask them how to contact the billing company as these are often seperate companies. I know it is all very confusing and to be truthful we think the standard of care should be the 76811. Hope this helps...
from the society of maternal fetal medicine, 2004
White Paper on Ultrasound Code 76811
Originally published in 2004.

The January 2003 CPT book published by the American Medical Association contains a new code (76811) for a procedure described as “Ultrasound, pregnant uterus, real time with image documentation, maternal evaluation plus detailed fetal anatomic examination, transabdominal, single or first gestation”. This new code is intended to describe the extensive fetal examinations that have become possible over the last decade and that have variously been known as “Level II”, “targeted”, “comprehensive” or “genetic” scans.

Because this new code will be assigned more RVUs than the basic obstetrical sonogram (76805), the Society for Maternal-Fetal Medicine believes that the new code describes an examination involving significantly more work, and requiring greater expertise than that required for 76805. Additionally, sophisticated equipment, rather than typical office level ultrasound machines, will be required to obtain the necessary imaging detail.

The work included under this new code can be divided into that occurring before, during and after the actual ultrasound. Particularly for the identification of fetal anomalies, there is greater importance in ensuring that proper historic information is available before the technical performance of the ultrasound, and that proper counseling occurs after the images are obtained. Therefore it is essential to recognize that the additional technologic sophistication and imaging expertise are merely the tip of the iceberg in meeting the requirements of CPT 76811.

The pre-service work includes review of clinical information, including relevant personal and family history, exposures and other risk factors. It also includes review of pertinent prior imaging study reports or the images themselves as available.

The intra-service work includes performance of the examination or supervision of the sonographer performing the examination, and interpretation of the examination. It is not possible to specify all of the possible components of this examination, and in any case the proper components will vary with the clinical needs of the patient.

The clinical service encompassed by CPT code 76811 will include all of the components of the complete obstetrical sonogram (CPT 76805), which has been defined similarly by the American College of Obstetricians and Gynecologists, the American College of Radiology, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine. CPT 76805 includes evaluation of the following fetal and maternal components in the second and third trimesters:

• Uterus and cervix
• Adnexal evaluation, when feasible
• Fetal number
• Presence of cardiac activity and movement
• Presentation
• Qualitative amniotic fluid volume (Amniotic Fluid Index not required)
• Placental location and number of cord vessels
• Fetal gestational age assessment by multiple measurements including:
o biparietal diameter
o Abdominal circumference
o Head circumference
o Femur length
o Estimation of fetal weight (in the third trimester)
Fetal anatomic screen including identification of:
o Cerebral ventricles
o Posterior fossa with cerebellar diameter
o Spine
o Stomach
o Kidneys and bladder
o Cord insertion site and ventral wall
Four chamber view of the fetal heart
CPT 76805 does not include an extensive analysis of fetal anatomy, the essential difference between 76805 and 76811. Examples of the more comprehensive fetal anatomic survey integral to 76811 follow. Not all will be required in all patients. Components considered integral to the code are marked (*).

Evaluation of intracranial, facial and spinal anatomy:
• Lateral ventricles*, third and fourth ventricles
• Cerebellum*, integrity of lobes*, vermis*
• Cavum septum pellucidum
• Cisterna magna measurement*
• Nuchal thickness measurement (15-20 weeks)*
• Integrity of cranial vault
• Examination of brain parenchyma, (e.g. for calcifications)
• Ear position, size
• Face
o Upper lip integrity*
o Palate*
o Mandible size
o Facial profile*
o Orbital sizes and separation (e.g. hypertelorism, hypotelorism)
Evaluation of the neck (e.g. for masses)

Evaluation of the chest:
• Presence of masses*
• Pleural effusion*
• Integrity of both sides of the diaphragm*
• Appearance of lung parenchyma*
• Appearance of ribs
Evaluation of the heart:
• Cardiac location and axis*
• Outflow tracts*
• Echogenicity
Evaluation of the abdomen:
• Bowel echogenicity*
• Adrenal glands
• Gallbladder
• Liver
• Spleen
• Ascites*
• Masses
• Calcifications
Evaluation of genitalia:
• Gender (whether or not parents wish to know sex of child)
Evaluation of limbs:
• Number, size, and architecture*
• Anatomy and position of hands*
• Anatomy and position of feet*
Evaluation of the placenta and cord:
• Placental cord insertion site*
• Placental masses*
• Umbilical-cord (number of arteries)
Evaluation of amniotic fluid:
• Semi-quantitative evaluation (Amniotic Fluid Index) when appropriate
After the sonogram is completed, the post-service work considered a portion of the 76811 code includes:
• Preparing a comprehensive report for the medical record
• Discussing the findings with the patient and referring physician when appropriate
• Reviewing and signing the prepared report
While conveying the results of the ultrasound to the patient is considered a component of the ultrasound charge, counseling or any further discussion with the patient if there are abnormal findings, and developing management/treatment plan options are not considered a component of the ultrasound report. These can therefore be reported separately, and billed with the appropriate evaluation and management code.

However, the Maternal-Fetal Medicine Specialist cannot assume that the requesting physician also wants a separate consultation when asked to perform a procedure. In order to report a consultation you will need:
• A written or verbal request for a consult made by a physician or other provider (e.g. CNM) and documented in the patient’s medical record
• The consultant’s opinion and any services performed must be documented in the patient’s medical record and communicated by written report to the requesting physician or other provider.
For obstetricians and radiologists, the level of expertise required to perform the 76811 examination can generally only be obtained through the extended education beyond residency that is acquired in a fellowship in Maternal-Fetal Medicine or Radiology. This education might also be acquired in specialized ultrasound fellowships, should those be developed in the future. As for any highly specialized procedure, some general obstetricians may have sufficient expertise to perform them well, but constant exposure to the latest equipment, literature and techniques in obstetrical ultrasound are necessary for the proper application of this code. Use of this code by general obstetricians should be the exception rather than the rule.

The Society for Maternal-Fetal Medicine also reminds the providers that the responsibility for the information in any sonogram, and the interpretation of the images, rests with the physician, not the sonographer. Only properly trained physicians should use this code, irrespective of the sonographer’s training or experience.

Addendum

The Coding Committee would like to clear up some confusion about ultrasound code 76811 for a detailed fetal anatomic exam. The Committee has written a white paper to help clarify what this ultrasound is and what the components of the study are.

There remain questions on how to use this ultrasound code. Additional technological sophistication and imaging expertise is needed to do this scan. This complexity was taken into consideration when this code was developed through the cooperation of the American Institute of Ultrasound and Medicine (AIUM), the American College of Ob/Gyn (ACOG), American College of Radiology (ACR), and the Society for Maternal-Fetal Medicine (SMFM) and is recognized by the increase in RVUs assigned to it.

CPT 76811 is not intended to be the routine scan performed for all pregnancies. Rather, it is intended for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan this pregnancy, etc.). Thus, the performance of CPT 76811 is expected to be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal anomalies.

It is felt by all organizations involved in the codes development and description that only one medically indicated CPT 76811 per pregnancy, per practice is appropriate. Once this detailed fetal anatomical exam (76811) is done, a second one should not be performed unless there are extenuating circumstances with a new diagnosis. It is appropriate to use CPT 76811 when a patient is seen by another maternal-fetal medicine specialist practice, for example, for a second opinion on a fetal anomaly, or if the patient is referred to a tertiary center in anticipation of delivering an anomalous fetus at a hospital with specialized neonatal capabilities.

Follow-up ultrasound for CPT 76811 should be CPT 76816 when doing a focused assessment of fetal size by measuring the BPD, abdominal circumference, femur length, or other appropriate measurements, OR a detailed re-examination of a specific organ or system known or suspected to be abnormal. CPT 76805 would be used for a fetal maternal evaluation of the number of fetuses, amniotic/chorionic sacs, survey of intracranial, spinal, and abdominal anatomy, evaluation of a 4-chamber heart view, assessment of the umbilical cord insertion site, assessment of amniotic fluid volume, and evaluation of maternal adnexa when visible when appropriate.

We hope this clears up any confusion regarding the use of the detailed fetal anatomical exam (76811).
This is great information outlining the difference between codes. Your information states..."CPT 76811 is not intended to be the routine scan performed for all pregnancies." Is it not the standard of care in most dedicated outpatient ultrasound imaging departments to perform this detailed of an exam for every pregnancy, regardless of risk? Do most imaging departments include more of the 76811 list than the 76805? The list of components for 76805 seems much too vague for what we think is the standard of care. What about components like evaluation of extremities, checking for cleft lip/palate, nuchal fold, profile? None of these are done with a 76805 but seem to be included in AIUM's Practice Guideline for OB for "standard fetal exam".

Anthony (Tony) Johnson said:
from the society of maternal fetal medicine, 2004
White Paper on Ultrasound Code 76811
Originally published in 2004.

The January 2003 CPT book published by the American Medical Association contains a new code (76811) for a procedure described as “Ultrasound, pregnant uterus, real time with image documentation, maternal evaluation plus detailed fetal anatomic examination, transabdominal, single or first gestation”. This new code is intended to describe the extensive fetal examinations that have become possible over the last decade and that have variously been known as “Level II”, “targeted”, “comprehensive” or “genetic” scans.

Because this new code will be assigned more RVUs than the basic obstetrical sonogram (76805), the Society for Maternal-Fetal Medicine believes that the new code describes an examination involving significantly more work, and requiring greater expertise than that required for 76805. Additionally, sophisticated equipment, rather than typical office level ultrasound machines, will be required to obtain the necessary imaging detail.

The work included under this new code can be divided into that occurring before, during and after the actual ultrasound. Particularly for the identification of fetal anomalies, there is greater importance in ensuring that proper historic information is available before the technical performance of the ultrasound, and that proper counseling occurs after the images are obtained. Therefore it is essential to recognize that the additional technologic sophistication and imaging expertise are merely the tip of the iceberg in meeting the requirements of CPT 76811.

The pre-service work includes review of clinical information, including relevant personal and family history, exposures and other risk factors. It also includes review of pertinent prior imaging study reports or the images themselves as available.

The intra-service work includes performance of the examination or supervision of the sonographer performing the examination, and interpretation of the examination. It is not possible to specify all of the possible components of this examination, and in any case the proper components will vary with the clinical needs of the patient.

The clinical service encompassed by CPT code 76811 will include all of the components of the complete obstetrical sonogram (CPT 76805), which has been defined similarly by the American College of Obstetricians and Gynecologists, the American College of Radiology, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine. CPT 76805 includes evaluation of the following fetal and maternal components in the second and third trimesters:

• Uterus and cervix
• Adnexal evaluation, when feasible
• Fetal number
• Presence of cardiac activity and movement
• Presentation
• Qualitative amniotic fluid volume (Amniotic Fluid Index not required)
• Placental location and number of cord vessels
• Fetal gestational age assessment by multiple measurements including:
o biparietal diameter
o Abdominal circumference
o Head circumference
o Femur length
o Estimation of fetal weight (in the third trimester)
Fetal anatomic screen including identification of:
o Cerebral ventricles
o Posterior fossa with cerebellar diameter
o Spine
o Stomach
o Kidneys and bladder
o Cord insertion site and ventral wall
Four chamber view of the fetal heart
CPT 76805 does not include an extensive analysis of fetal anatomy, the essential difference between 76805 and 76811. Examples of the more comprehensive fetal anatomic survey integral to 76811 follow. Not all will be required in all patients. Components considered integral to the code are marked (*).

Evaluation of intracranial, facial and spinal anatomy:
• Lateral ventricles*, third and fourth ventricles
• Cerebellum*, integrity of lobes*, vermis*
• Cavum septum pellucidum
• Cisterna magna measurement*
• Nuchal thickness measurement (15-20 weeks)*
• Integrity of cranial vault
• Examination of brain parenchyma, (e.g. for calcifications)
• Ear position, size
• Face
o Upper lip integrity*
o Palate*
o Mandible size
o Facial profile*
o Orbital sizes and separation (e.g. hypertelorism, hypotelorism)
Evaluation of the neck (e.g. for masses)

Evaluation of the chest:
• Presence of masses*
• Pleural effusion*
• Integrity of both sides of the diaphragm*
• Appearance of lung parenchyma*
• Appearance of ribs
Evaluation of the heart:
• Cardiac location and axis*
• Outflow tracts*
• Echogenicity
Evaluation of the abdomen:
• Bowel echogenicity*
• Adrenal glands
• Gallbladder
• Liver
• Spleen
• Ascites*
• Masses
• Calcifications
Evaluation of genitalia:
• Gender (whether or not parents wish to know sex of child)
Evaluation of limbs:
• Number, size, and architecture*
• Anatomy and position of hands*
• Anatomy and position of feet*
Evaluation of the placenta and cord:
• Placental cord insertion site*
• Placental masses*
• Umbilical-cord (number of arteries)
Evaluation of amniotic fluid:
• Semi-quantitative evaluation (Amniotic Fluid Index) when appropriate
After the sonogram is completed, the post-service work considered a portion of the 76811 code includes:
• Preparing a comprehensive report for the medical record
• Discussing the findings with the patient and referring physician when appropriate
• Reviewing and signing the prepared report
While conveying the results of the ultrasound to the patient is considered a component of the ultrasound charge, counseling or any further discussion with the patient if there are abnormal findings, and developing management/treatment plan options are not considered a component of the ultrasound report. These can therefore be reported separately, and billed with the appropriate evaluation and management code.

However, the Maternal-Fetal Medicine Specialist cannot assume that the requesting physician also wants a separate consultation when asked to perform a procedure. In order to report a consultation you will need:
• A written or verbal request for a consult made by a physician or other provider (e.g. CNM) and documented in the patient’s medical record
• The consultant’s opinion and any services performed must be documented in the patient’s medical record and communicated by written report to the requesting physician or other provider.
For obstetricians and radiologists, the level of expertise required to perform the 76811 examination can generally only be obtained through the extended education beyond residency that is acquired in a fellowship in Maternal-Fetal Medicine or Radiology. This education might also be acquired in specialized ultrasound fellowships, should those be developed in the future. As for any highly specialized procedure, some general obstetricians may have sufficient expertise to perform them well, but constant exposure to the latest equipment, literature and techniques in obstetrical ultrasound are necessary for the proper application of this code. Use of this code by general obstetricians should be the exception rather than the rule.

The Society for Maternal-Fetal Medicine also reminds the providers that the responsibility for the information in any sonogram, and the interpretation of the images, rests with the physician, not the sonographer. Only properly trained physicians should use this code, irrespective of the sonographer’s training or experience.

Addendum

The Coding Committee would like to clear up some confusion about ultrasound code 76811 for a detailed fetal anatomic exam. The Committee has written a white paper to help clarify what this ultrasound is and what the components of the study are.

There remain questions on how to use this ultrasound code. Additional technological sophistication and imaging expertise is needed to do this scan. This complexity was taken into consideration when this code was developed through the cooperation of the American Institute of Ultrasound and Medicine (AIUM), the American College of Ob/Gyn (ACOG), American College of Radiology (ACR), and the Society for Maternal-Fetal Medicine (SMFM) and is recognized by the increase in RVUs assigned to it.

CPT 76811 is not intended to be the routine scan performed for all pregnancies. Rather, it is intended for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan this pregnancy, etc.). Thus, the performance of CPT 76811 is expected to be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal anomalies.

It is felt by all organizations involved in the codes development and description that only one medically indicated CPT 76811 per pregnancy, per practice is appropriate. Once this detailed fetal anatomical exam (76811) is done, a second one should not be performed unless there are extenuating circumstances with a new diagnosis. It is appropriate to use CPT 76811 when a patient is seen by another maternal-fetal medicine specialist practice, for example, for a second opinion on a fetal anomaly, or if the patient is referred to a tertiary center in anticipation of delivering an anomalous fetus at a hospital with specialized neonatal capabilities.

Follow-up ultrasound for CPT 76811 should be CPT 76816 when doing a focused assessment of fetal size by measuring the BPD, abdominal circumference, femur length, or other appropriate measurements, OR a detailed re-examination of a specific organ or system known or suspected to be abnormal. CPT 76805 would be used for a fetal maternal evaluation of the number of fetuses, amniotic/chorionic sacs, survey of intracranial, spinal, and abdominal anatomy, evaluation of a 4-chamber heart view, assessment of the umbilical cord insertion site, assessment of amniotic fluid volume, and evaluation of maternal adnexa when visible when appropriate.

We hope this clears up any confusion regarding the use of the detailed fetal anatomical exam (76811).
It seems to me that for the most part 76811 is for high risk pregnancies, but since 76805 is so vague than some billers will choose to use it. Also it says that 76811 came into existence in 2003. What was used prior to that then for non-high risk 20 week ultrasounds?
IT is my understanding, that unless a MFM is on-site for ultrasound and it is done at a perinatal center, that 76805 should be used.

Laura (Gilmore) Craven said:
It seems to me that for the most part 76811 is for high risk pregnancies, but since 76805 is so vague than some billers will choose to use it. Also it says that 76811 came into existence in 2003. What was used prior to that then for non-high risk 20 week ultrasounds?
I would recommend that you go back to your provider and have them resubmit a 78805 so your insurance will cover it. The 76811 is "indication driven" so unless you physician's office can come up with a valid high-risk condition (diagnosis code) that would justify the performance of this exam they can't charge for it. They are certainly welcome to go above and beyond what is required in the exam for the 76805 and evaluate more anatomy than stated in the CPT book but cannot charge for it. If they will not change the charge, they need to write a letter to your insurance company justifying the higher order charge so that this can get covered. Hope this helps. The 2010 CPT book does mention the components for each exam.
Thank you everyone that put a comment up on here for me. I have a much better understanding what is going on right now. I will be contacting both the biller AND my OB to get this taken care of once and for all. I appreciate everyone's input!! Thank you again for your help!

RSS

© 2014   Created by Glynis Harvey.

Badges  |  Report an Issue  |  Terms of Service