Coding

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76811 billing guidelines

  • 1.  76811 billing guidelines

    Posted 07-02-2021 19:27
    We have a number of non-AIUM accredited general OB/GYN's in the hospital systems who routinely bill for 76811. I know in some states medicaid will limit this code to MFM's. I  live in Colorado and can't find if this code is supposed to be limited to MFM's. Do you know how I would go about looking for this information?

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    Sarah Anderson
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  • 2.  RE: 76811 billing guidelines

    Posted 07-03-2021 17:43
    I am curious about this as well. I would assume you must have a higher level of training to apply this code & be reimbursed and at least be AIUM certified if you are not board certified as a Maternal Fetal Medicine Specialist with ABOG.
    Curious as to the exact requirements and if private insurance has the same restrictions as Medical - Medicaid etc. Kathleen Bradley MD MFM in California

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    Kathleen Bradley MD
    MFM
    Private practice
    Westlake Village, CA
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  • 3.  RE: 76811 billing guidelines

    Posted 07-03-2021 18:30
    I can't speak to Colorado. But in VT (and I would assume other states), there is no screening for whether you are an MFM or not. Indeed, you technically don't need to be an MFM to do a 76811. There are certainly highly qualified radiologists and perhaps even some OBGYNs with extra training. In VT, you don't need to be AIUM accredited to bill for any particular ultrasound. So I suspect there isn't a limitation. We have also seen OBGYNs bill for 76811 and when the scans were reviewed, they were not even well-done 76805 scans. I would be happy to see some better oversight, but unless insurers and Medicaid start requiring AIUM accreditation (or ACR), I don't think it is going to happen any time soon.


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    David Jones
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  • 4.  RE: 76811 billing guidelines

    Posted 07-03-2021 20:20
    Hi Sarah,
    The CPT code itself does not specify which subspecialties can bill it, nor does it require certification by AIUM or others. However, payers may set their own rules that require certain subspecialties (e.g. MFMs) or certification (e.g. AIUM) before they will allow reimbursement. The "Consensus Report on the Detailed Fetal Anatomic Ultrasound Examination - Indications, Components, and Qualifications drafted by the 76811 Task Force on behalf of multiple national societies (J Ultrasound Med 2014; 33:189–195) specifies the qualifications and necessary training to perform and/or interpret the detailed fetal anatomic ultrasound examination. Most (but not all) payers require those qualifications included in that consensus for payment of 76811. Billing 76811 by some without possessing the qualifications to perform or interpret the study does raise serious concerns for those individuals.
    Fadi

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    Fadi BSAT, MD
    Past Chair, SMFM Coding Committee
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  • 5.  RE: 76811 billing guidelines

    Posted 07-04-2021 23:48
    Agree Fadi

    The 2017 executive summary on quality by smfm (B. Iriye) identified this specialization/ accreditation as an important quality/safety issue as well.  https://www.ajog.org/article/S0002-9378(17)30860-8/fulltext

    We know it's an issue, continuing to advocate this with payers is something SMFM continues to prioritize. You can try to discuss with with the payers/medical directors. This article & the one Fadi linked may be useful in that regard



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    Vanita Jain, MD
    Chair, SMFM Coding Committee
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  • 6.  RE: 76811 billing guidelines

    Posted 08-04-2021 18:30
    Thank you for all the thoughtful and knowledgeable responses. I do not care who bills for it as long as they have the proper training and document and archive what they see. Thank you and stay safe/healthy. kb

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    Kathleen Bradley MD
    MFM
    Private practice
    Westlake Village, CA
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  • 7.  RE: 76811 billing guidelines

    Posted 08-23-2021 11:30
    Some of our patients 76 811 scans are extremely limited by body habitus and fetal position. Is there a certain point where it's so limited that it's no longer appropriate the bill 76 811?

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    Matthew Mingione
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  • 8.  RE: 76811 billing guidelines

    Posted 08-23-2021 12:49
    Hi Matthew,
    As long as each of the 76811 elements is marked (e.g. visualized or normal, abnormal, poorly visualized, not well seen, etc.), you can still bill 76811. In other words, you should not only mark the visualized elements and leave the other blank. Most imaging software should be able to do that.
    Fadi

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    Fadi BSAT, MD
    Past Chair, SMFM Coding Committee
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