Obstetrical Ultrasonography 76825
User Manual: 76825
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UnitedHealthcare® Oxford Clinical Policy OBSTETRICAL ULTRASONOGRAPHY Policy Number: RADIOLOGY 013A.21 T2 Effective Date: December 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 CONDITIONS OF COVERAGE...................................... 1 BENEFIT CONSIDERATIONS ...................................... 2 COVERAGE RATIONALE ............................................. 2 APPLICABLE CODES ................................................. 3 BACKGROUND ......................................................... 4 REFERENCES ........................................................... 4 POLICY HISTORY/REVISION INFORMATION ................. 5 Related Policy Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership. Benefit Type General benefits package Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations No Obstetrical Ultrasonography UnitedHealthcare Oxford Clinical Policy No1, 2 No Home, Outpatient, Office 1 The fourth and subsequent ultrasound procedures per pregnancy require precertification for participating providers as outlined in this policy by eviCore healthcare. 2 Refer to the Benefits Consideration section for precertification guidelines for New Jersey (NJ) Small group plans, NJ Individual plans (for Date of Service (DOS) prior to 01/01/17, NJ School Board plans and NJ Municipality plans. ©1996-2017, Oxford Health Plans, LLC Page 1 of 5 Effective 12/01/2017 BENEFIT CONSIDERATIONS Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable. New Jersey (NJ) Small, NJ Individual (for Date of Service (DOS) prior to 01/01/17), NJ School Board and NJ Municipality Products Services indicated as requiring a precertification require medical necessity review. This review may be requested prior to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to rendering the service. It is the referring physician’s responsibility to provide medical documentation to demonstrate clinical necessity for the study that is being requested (for review prior to service) or has been rendered (for review after service was provided). Essential Health Benefits for Individual and Small Group For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage. COVERAGE RATIONALE This policy has three components: 1. Utilization Management Participating Providers will be reimbursed in accordance to their contract, for up to three ultrasounds per pregnancy, based upon their specialty and applicable payment rules, without precertification as outlined in section II and III of this policy. The fourth and subsequent obstetrical ultrasound procedure per Member per pregnancy performed by a participating provider as outlined are subject to utilization review (pre-certification) by eviCore healthcare. Oxford has engaged eviCore healthcare to perform initial reviews of requests for pre-certification and Medical necessity reviews. To pre-certify a radiology procedure, please call eviCore healthcare at 1-877-PRE-AUTH (1-877773-2884) or log on to the eviCore healthcare web site using the Prior Authorization and Notification App. eviCore healthcare has established an infrastructure to support the review, development, and implementation of comprehensive outpatient imaging criteria. The radiology evidence-based guidelines and management criteria are available on the eviCore healthcare web site: http://www.carecorenational.com/page/criteria.aspx. 2 & 3. Payment by Specialty & Accreditation/Certification Requirements Specialists will be reimbursed for radiology services rendered in the office, outpatient or home setting. Services are payable to participating physicians based on their specialty. In addition, certain ultrasounds may not be reimbursed unless the providers hold a particular accreditation. a. Reproductive Endocrinologists may perform the following ultrasound CPT codes; precertification for the fourth and subsequent procedures per Member per pregnancy is required: 76815, 76816, 76817 *In addition to the codes listed above a Reproductive Endocrinologist, with an AIUM/ACR accreditation may perform the following studies; precertification for the fourth and subsequent procedure per Member per pregnancy is required: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828 b. Obstetricians/Gynecologists may perform the following ultrasound CPT codes; precertification for the fourth and subsequent procedure per Member per pregnancy is required: 76815, 76816, 76817 *In addition to the codes listed above an Obstetrician/Gynecologist, with an AIUM or ACR accreditation may perform the following studies; precertification for the fourth and subsequent procedure per Member per pregnancy is required: Obstetrical Ultrasonography UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 2 of 5 Effective 12/01/2017 c. d. 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828 Maternal Fetal Medicine and Perinatal Neonatal Medicine specialists may perform the following ultrasound CPT codes; precertification for the fourth and subsequent procedure per Member per pregnancy is required: 76815, 76816, 76817 *In addition to the codes listed above a Maternal Fetal Medicine and Perinatal Neonatal Medicine specialist, with an AIUM or ACR accreditation may perform the following studies, precertification for the fourth and subsequent procedure per Member per pregnancy is required: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826, 76827, 76828 Board Certified Pediatric Cardiologists with the American Board of Pediatrics and Cardiology Laboratories accredited by the Intersocietal Accreditation Commission for Echocardiography may perform the following ultrasound CPT codes; precertification for the fourth and subsequent procedure per Member per pregnancy is required: 76825-76828 APPLICABLE CODES The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. Payment guidelines are applicable to participating providers only. CPT code 76805 will be reimbursed two times per pregnancy if billed by two different providers and the provider has not already billed a 76811 - if 76805 is billed multiple times, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816). CPT code 76810 will be reimbursed one time per fetus - if 76810 is billed more than one time per fetus, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816). CPT code 76811 will be reimbursed two times per pregnancy if billed by two different providers. If 76811 is billed multiple times by the same provider, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816). CPT code 76812 will be reimbursed one time per fetus - if 76812 is billed is billed more than one time per fetus, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816). CPT code 76813 will be reimbursed one time per pregnancy for a single fetus or first of a multiple gestation. CPT code 76814 will be reimbursed (in addition to CPT code 76813) one time per pregnancy for each additional fetus of a multiple gestation. CPT code 76820 will be reimbursed one time per fetus per date of service. CPT code 76821 will be reimbursed one time per fetus per date of service. CPT code 76825 will be reimbursed one time per fetus - if 76825 is billed is billed more than one time per fetus, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76826). CPT code 76827 will be reimbursed one time per fetus - if 76827 is billed is more than one time per fetus, claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76828). Evaluation and management (E&M) codes will be reimbursed on the same date of service as an obstetrical ultrasound only when the service is separate and distinct from routine antepartum care, as indicated by appending modifier -25. CPT Code 76801 Description Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation 76802 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) 76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation 76810 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Obstetrical Ultrasonography UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 3 of 5 Effective 12/01/2017 CPT Code 76811 Description Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation 76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) 76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation 76814 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position, and/or qualitative amniotic fluid volume), one or more fetuses 76816 Ultrasound, pregnant uterus, real time with image documentation, follow up (e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), trans abdominal approach per fetus. 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal; for non-obstetrical transvaginal ultrasound use 76830; If transvaginal examination is done in addition to transabdominal obstetrical ultrasound exam, use 76817 in addition to appropriate transabdominal exam code. 76818 Fetal biophysical profile; with non-stress testing 76819 Fetal biophysical profile; without non-stress testing 76820 Doppler velocimetry, fetal; umbilical artery 76821 Doppler velocimetry, fetal; middle cerebral artery 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D) with or without M-mode recording 76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D) with or without M-mode recording; follow up or repeat study 76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete 76828 Doppler echocardiography, fetal pulsed wave and/or continuous wave with spectral display; follow up or repeat study CPT® is a registered trademark of the American Medical Association BACKGROUND Obstetric Ultrasound is a highly developed technique used to detect ectopic pregnancy and multiple pregnancies, assessing fetal life and function, diagnosing physical anomalies, and guiding physicians in their efforts to treat the fetus. Although the clinical benefit of routine ultrasonography has not been established, it is commonly performed early in pregnancy for confirmation of dates, fetal viability, and pregnancy location. Later studies at 16-20 weeks are used to assess fetal anatomy and to identify potential fetal abnormalities. In addition, there are a variety of complications that require ultrasound for evaluation. REFERENCES American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins - Obstetrics. Ultrasonography in pregnancy. ACOG Practice Bulletin No. 58. Washington, DC: ACOG; December 2004. American College of Obstetricians and Gynecologists. Ultrasonography in Pregnancy. Technical Bulletin no. 187, 1993. American Institute of Ultrasound in Medicine: Standards of Performance. Antepartum Obstetrical Ultrasound Examination. American Medical Association. Current Procedural Terminology: CPT Professional Edition. Obstetrical Ultrasonography UnitedHealthcare Oxford Clinical Policy ©1996-2017, Oxford Health Plans, LLC Page 4 of 5 Effective 12/01/2017 Lefevre ML, Bain RP, Ewigman BG et al. A randomized trial of prenatal ultrasonographic screening: impact on maternal management and outcome. The RADIUS Study Group. Am.J. Obstet Gynecol 1993; 169:483-489. National Institutes of Health Consensus Development Conference. The use of diagnostic ultrasound imaging during pregnancy. JAMA 1984, 252: 669-672. Society for Maternal-Fetal Medicine (SMFM), Coding Committee. White paper on ultrasound code 76811. Announcements. Washington, DC: SMFM; May 24, 2004. Available at: www.smfm.org. POLICY HISTORY/REVISION INFORMATION Date 12/01/2017 Obstetrical Ultrasonography UnitedHealthcare Oxford Clinical Policy Action/Description Updated language pertaining to the precertification request process; added reference link to the Prior Authorization and Notification App Archived previous version RADIOLOGY 013A.20 T2 ©1996-2017, Oxford Health Plans, LLC Page 5 of 5 Effective 12/01/2017
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