Hi Aldo,
This is a payer-specific policy as CMS does not have such rule and the CPT descriptions of the corresponding codes do NOT restrict performing a 76817 when a fetal anatomy survey (76805 or 76811) is done during the same encounter. This problem has already been faced by SMFM members in other states. We created an advocacy letter that will help you appeal this arbitrary rule with the payers. It is endorsed by both SMFM and ACOG and you can find it on the Coding section of the SMFM website at
https://s3.amazonaws.com/cdn.smfm.org/media/1112/Coding.pdfUnless your contract (which you agreed to when signed) with the payer specifically prohibits doing both studies during the same encounter, this advocacy letter should hopefully help you in your appeal to reverse this payer policy as it did for other members already.
Best Regards,
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Fadi Bsat, MD
Past Chair, SMFM Coding Committee
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Original Message:
Sent: 02-11-2020 16:12
From: Aldo Khoury
Subject: 2020 TVS/SURVEY DENIALS
Hello all. I'm currently in New Jersey and as of the beginning of this year I am suddenly seeing denials from NJ Medicaid HMO payers (Horizon NJ Health, Aetna Better Health) when I attempt to bill a transabdominal survey (76811 or 76805) with a transvaginal to rule out cervical shortening (76817) together. These payers have always reimbursed these ultrasounds as separate and distinct services. Does anyone have any insight into new CMS policies that may be causing this? I know there were a number of bundling changes from CMS beginning in 2020 but I do not see anything related to these particular services. Thank you for your help.
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Aldo Khoury MD FACOG
Perinatal Services of Northern New Jersey
57 Willowbrook Blvd
Suite 301
Wayne, NJ 07470
973-754-3800
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