Coding

  • 1.  2020 TVS/SURVEY DENIALS

    Posted 02-11-2020 16:13
    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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  • 2.  RE: 2020 TVS/SURVEY DENIALS

    Posted 02-12-2020 08:12
    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.pdf
    Unless 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


  • 3.  RE: 2020 TVS/SURVEY DENIALS

    Posted 02-12-2020 08:55

    Although I am in Georgia – I got a notice from one of our Medicaid HMO payers that a -52 modifier had to now be attached to any transvaginal ultrasound when done with another ultrasound.

     

    We have been fighting this as it would reduce the reimbursement and they have delayed implementing at this point, may be something to look into on the CMS guidelines for this code.

     

    Jolene M. Reeves, CCS-P

    Director of Revenue Cycle

    Women's Telehealth    

    990 Hammond Drive

    Suite 120

    Atlanta, GA  30328

    Office:  (404) 478-3017

    Fax:  (855) 894-0186

    Mobile:  (678) 638-9118

                                                       

     

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    Original Message


  • 4.  RE: 2020 TVS/SURVEY DENIALS

    Posted 02-12-2020 09:46
    Hello Jolene,
    There are no CMS guidelines or CPT description or rule mandating the use of -52 or prohibiting the use of the 2 codes together. This is an arbitrary payer policy that should be reversed. Unsure if you saw my earlier reply to Aldo. The advocacy letter we created covers that as well and can be found at https://s3.amazonaws.com/cdn.smfm.org/media/1112/Coding.pdf
    Best Regards,

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    Fadi Bsat, MD
    Past Chair, SMFM Coding Committee
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    Original Message


  • 5.  RE: 2020 TVS/SURVEY DENIALS

    Posted 02-12-2020 17:26
    Dr. Khoury
    Thank you for reaching out, unfortunately this is an issue we have seen in other states. 
    Please utilize this letter on our website:  https://s3.amazonaws.com/cdn.smfm.org/media/1112/Coding.pdf
    It may help with your appeals process. 
    Best,

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    Vanita Jain, MD
    Chair, SMFM Coding Committee
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    Original Message