Coding

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?

------------------------------
Sarah Anderson
------------------------------

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

------------------------------
Kathleen Bradley MD
MFM
Private practice
Westlake Village, CA
------------------------------

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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.


------------------------------
David Jones
------------------------------

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee
------------------------------

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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 



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee
------------------------------

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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?

------------------------------
Matthew Mingione
------------------------------

Original Message:
Sent: 07-04-2021 23:48
From: Vanita Jain
Subject: 76811 billing guidelines

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



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee
------------------------------

Original Message:
Sent: 08-23-2021 11:30
From: Matthew Mingione
Subject: 76811 billing guidelines

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?

------------------------------
Matthew Mingione

Original Message:
Sent: 07-04-2021 23:48
From: Vanita Jain
Subject: 76811 billing guidelines

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



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

Can you remark on the indications for 76811- one of our partners remembered an SMFM coding class had suggested that missed genetic screening was an indication for 76811.  While this could be construed as an alternative to genetic screening if serologies were missed or unavailable, I can't find it anywhere in the consensus.   
Specific indications we are wondering about are missed genetic screening, declined genetic screening and late prenatal care.

------------------------------
Julia Bregand White
------------------------------

Original Message:
Sent: 08-23-2021 12:49
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 08-23-2021 11:30
From: Matthew Mingione
Subject: 76811 billing guidelines

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?

------------------------------
Matthew Mingione

Original Message:
Sent: 07-04-2021 23:48
From: Vanita Jain
Subject: 76811 billing guidelines

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



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

Hello Julia,

------------------------------
Fadi BSAT, MD, FAIUM
Past Chair, SMFM Coding Committee
------------------------------

Original Message:
Sent: 11-15-2021 20:12
From: Julia Bregand White
Subject: 76811 billing guidelines

Can you remark on the indications for 76811- one of our partners remembered an SMFM coding class had suggested that missed genetic screening was an indication for 76811.  While this could be construed as an alternative to genetic screening if serologies were missed or unavailable, I can't find it anywhere in the consensus.
Specific indications we are wondering about are missed genetic screening, declined genetic screening and late prenatal care.

------------------------------
Julia Bregand White

Original Message:
Sent: 08-23-2021 12:49
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 08-23-2021 11:30
From: Matthew Mingione
Subject: 76811 billing guidelines

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?

------------------------------
Matthew Mingione

Original Message:
Sent: 07-04-2021 23:48
From: Vanita Jain
Subject: 76811 billing guidelines

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



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

Fadi, 

Do you know the proper way to bill for an incorrectly scheduled 1st trimester screen?  (as in they thought the patient was 12 weeks and they are actually 16wk)

I was trained that you can either bill/complete a limited or bill a 76805/76811 and subopt what you don't see and they return for a follow up at 20 weeks?

------------------------------
Megan Varvoutis
------------------------------

Original Message:
Sent: 08-23-2021 12:49
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 08-23-2021 11:30
From: Matthew Mingione
Subject: 76811 billing guidelines

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?

------------------------------
Matthew Mingione

Original Message:
Sent: 07-04-2021 23:48
From: Vanita Jain
Subject: 76811 billing guidelines

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



------------------------------
Vanita Jain, MD
Chair, SMFM Coding Committee

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------

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

------------------------------
Kathleen Bradley MD
MFM
Private practice
Westlake Village, CA
------------------------------

Original Message:
Sent: 07-03-2021 20:20
From: Fadi BSAT
Subject: 76811 billing guidelines

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

------------------------------
Fadi BSAT, MD
Past Chair, SMFM Coding Committee

Original Message:
Sent: 07-02-2021 19:27
From: Sarah Anderson
Subject: 76811 billing guidelines

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?

------------------------------
Sarah Anderson
------------------------------