Hi Elizabeth,
Obesity is not an indication for fetal echocardiogram. A suboptimally seen 4-chamber view deserves a follow-up study 76816. However, if a cardiac anomaly is suspected on the detailed fetal anatomy, then the fetal echo would be indicated (though may end up being normal).
You can find all the ICD-10 indications for fetal echo listed at
https://doi.org/10.1055/s-0041-1740004 or
https://pubmed.ncbi.nlm.nih.gov/34839475/ which follows the national guidelines from AIUM and others.
Fadi
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Fadi BSAT, MD, FAIUM
Chair, SMFM Practice Management Committee
Immediate past Chair, SMFM Coding Committee
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Original Message:
Sent: 10-18-2022 09:15
From: Elizabeth Fox
Subject: 76805 vs 76811 for Obesity
Fadi,
Are we able to charge 76825 for BMI >30? We have many referrals for suboptimal views and often the reason is BMI. I only find BMI as "other considerations" in AIUM literature but not here on SMFM list or Aetna's site. I do see Aetna suggests 76825 if the 4CH view is not cleared and of course, if abnormal. But, if 4CH is seen and normal, with other views are suboptimal, Aetna does not suggest 76825 if I am reading correctly.
Thanks for your help!
Elizabeth Fox
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Elizabeth Fox
Original Message:
Sent: 10-05-2022 09:19
From: Fadi BSAT
Subject: 76805 vs 76811 for Obesity
Hi Galina,
76811 is an indication driven code and most payers DO follow the national guidelines supported by all major organizations (SMFM, ACOG, AIUM, ACR, etc.). The exception would be if there is a contractual agreement with that payer to the contrary. If you have specific payers who do not accept 76811 for BMI > 30, please forward them the publications noted earlier in addition to the white papers from the SMFM Coding Committee. This will often help resolve the matter. If not, please share specific examples and SMFM can help advocate for you with that payer.
Fadi
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Fadi BSAT, MD, FAIUM
Chair, SMFM Practice Management Committee
Immediate past Chair, SMFM Coding Committee
Original Message:
Sent: 10-05-2022 00:42
From: Galina Tulman
Subject: 76805 vs 76811 for Obesity
I've been coding and billing for MFM's for the past 15 years insurance companies don't go by indications as sad as it sounds. Most payers and depending on what state you're in don't pay for 76811 if you will use obesity code. Depending on the payer and depending on the state you're in you have to know what insurance companies pay with what dx code. Its a game you have to know how to play as sad as it sounds. I'll be glad to help if you need more help.
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Galina Tulman
Original Message:
Sent: 09-29-2022 22:20
From: Blake Porter
Subject: 76805 vs 76811 for Obesity
All, thank so much for your insights.
Dr Bsat, the document from Aetna will surely prove useful in future negotiations (not all classes of obesity are currently viewed as indications for 76811 in my state).
Appreciate the help!!
Cheers,
-BWP
Original Message:
Sent: 9/29/2022 7:11:00 PM
From: Anthony Sciscione
Subject: RE: 76805 vs 76811 for Obesity
Thanks for the great question and Agree with Dr. Bsat. BMI > 30 is an indication for a detailed/advanced ultrasound. Tony
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Anthony Sciscione
Original Message:
Sent: 09-29-2022 17:52
From: Fadi BSAT
Subject: 76805 vs 76811 for Obesity
Hi Blake,
BMI > 30 is an indication for 76811. This is per the consensus among national societies and the corresponding ICD-10 list generated based on the consensus. These include ICD-10 range Z68.30-Z68.45 (Body mass index 30–70 kg/m2, adult). Payers, for the most part, support that or at least should. For example, here is Aetna's website: https://www.aetna.com/cpb/medical/data/100_199/0199.html
References:
- Consensus report on the 76811 scan: modification. J Ultrasound Med 2015; 34:1915.
- Bsat F. Detailed Fetal Anatomic Ultrasound Examination (76811): Updated ICD-10 Indications. J Ultrasound Med. 2022 Apr;41(4):1035-1036. doi: 10.1002/jum.15779. Epub 2021 Jul 7. PMID: 34232530.
Best,
Fadi
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Fadi BSAT, MD, FAIUM
Chair, SMFM Practice Management Committee
Immediate past Chair, SMFM Coding Committee
Original Message:
Sent: 09-29-2022 14:57
From: Blake Porter
Subject: 76805 vs 76811 for Obesity
All,
Interested in what type of anatomy US (76805 vs 76811) others perform around the country across different classes of obesity.
Please reply in the following format with the anatomy exam you perform:
Class I Obesity (BMI 30-34.9): 76805 vs 76811
Class II Obesity (BMI 35-39.9): 76805 vs 76811
Class III Obesity (BMI 40+): 76805 vs 76811
Lastly, if you have any documentation from your payors regarding Obesity and 76811 agreements, please send to me directly. Thanks so much for your time.
-Blake Porter, MD
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Blake Porter
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