Question:

I am finding that payers will not cover 76805 if 76801 has already been billed. Do you know why that is?

Answer:

Many insurances will only pay for one complete ultrasound. After a complete ultrasound has been done, other exams are considered follow-up or limited exams and would be billed with either 76815 or 76816. As stated in the Spring 2019 issue of Clinical Examples in Radiology, “Code 76816 is reported if a complete examination is performed to reassess fetal size, interval growth, or previously demonstrated anatomic abnormalities.” Follow-up code 76816 is reported regardless of whether the fetus is younger than 14 weeks 0 days or older than or equal to 14 weeks 0 days. It should be reported for each fetus after the first fetus that requires reevaluation, with modifier 59 appended to indicate separate and distinct procedures. That issue of Clinical Examples in Radiology also states, “When an obstetrical ultrasound procedure is performed for limited purposes (eg, fetal viability, fetal position, or amniotic fluid volume), code 76815 should be reported once per examination; it should not be reported per element or per fetus.”

Facebook
Twitter
LinkedIn

CPT® copyright 2024 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.

Unlock 50% off all 2024 edition books when you order by July 5! Use the coupon code CO5024 at checkout to claim this offer!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24