Notification

Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product


Notification Issue Date: 11/01/2017



Policy Attachment


Attachment to Policy # 00.03.10e


Attachment:B

Policy #:00.03.10e

Description:Rule out Ectopic Pregnancy

Title:Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



In certain circumstances, medically necessary obstetrical ultrasound services are eligible for reimbursement by the Company to participating providers or hospitals at a non-capitated site.

Specialists

The circumstances for which a Rule Out Ectopic pregnancy obstetrical ultrasound is eligible for reimbursement to a participating Obstetrics-Gynecology, Reproductive Endocrinology, Infertility, or Maternal Fetal Medicine, (this includes certified registered nurse practitioners (CRNPS) and Physician Assistants (PAs) practicing within these specialty groups), are outlined below.

Rule Out Ectopic Pregnancy
Obstetrics-Gynecology, Reproductive Endocrinology, Infertility, Maternal Fetal Medicine
(Office and Hospital Outpatient Place of Service Only)
Procedure Code
76815
76817
76830
76856
76857

ICD-10 Code
O00.101
O00.102
O00.109
O00.111
O00.112
O00.119
O00.201
O00.202
O00.209
O00.211
O00.212
O00.219
O00.80
O00.81
O00.90
O00.91
O09.A0
O09.A1
O09.A2
O09.A3
O09.10
O09.11
O09.12
O09.13
O20.0
O36.80X0
O36.80X1
O36.80X2
O36.80X3
O36.80X4
O36.80X5
O36.80X9

Outpatient Hospitals

The circumstances for which a Rule Out Ectopic pregnancy obstetrical ultrasound is eligible for reimbursement to the Outpatient Hospital are outlined below.

Procedure Code
76815
76817
76830
76856
76857

ICD-10 Code
O00.101
O00.102
O00.109
O00.111
O00.112
O00.119
O00.201
O00.202
O00.209
O00.211
O00.212
O00.219
O00.80
O00.81
O00.90
O00.91
O09.A0
O09.A1
O09.A2
O09.A3
O09.10
O09.11
O09.12
O09.13
O20.0
O36.80X0
O36.80X1
O36.80X2
O36.80X3
O36.80X4
O36.80X5
O36.80X9

Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A

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