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

This policy becomes effective 12/01/2017:

This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.



Claim Payment Policy


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

Policy #:00.03.10e

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Generally, members enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) products are required to obtain diagnostic radiology services at their Primary Care Physician's (PCP's) designated capitated diagnostic radiology site.

In certain circumstances, medically necessary obstetrical ultrasound services are eligible for reimbursement by the Company to participating providers at a non-capitated site.
  • Certain participating specialist types are eligible to provide specific diagnostic ultrasounds to HMO/HMO-POS members.
  • Hospitals that are not the member’s capitated radiology site may perform and be reimbursed for specific diagnostic ultrasound services.
    • If the hospital is the capitated radiology site for the member, these covered services are included in the capitation payment and no additional payment will be made.

The circumstances for which a participating provider or hospital is eligible for reimbursement at a non-capitated site are listed in attachments A, B, C and D of this policy:
  • Attachment A: High Risk Pregnancy
  • Attachment B: Rule out ectopic pregnancy
  • Attachment C: Rule out intrauterine pathology and Screening for fetal abnormalities
  • Attachment D: First-trimester screening and Ovarian Dysfunction

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, diagnostic ultrasound services are covered under the medical benefits of the Company’s products.

BILLING GUIDELINES

Health Maintenance Organization (HMO) Members do not require a Referral from their Primary Care Physician (PCP) for diagnostic ultrasound services provided by an Obstetrics and Gynecology (OB/GYN) specialists.

Description

Diagnostic radiology is the use of imaging modalities (e.g., x-ray, ultrasound) to obtain a diagnosis of a medical condition.

Capitation is the reimbursement that a participating facility, ancillary provider (eg, freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for a Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes their referred benefit.
References


Company Contracts




Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachments A, B, C, and D


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

Refer to Attachments A, B, and D


HCPCS Level II Code Number(s)

Refer to Attachments A, B, C, and D


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Description: High Risk Pregnancy

Attachment B: Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Description: Rule out Ectopic Pregnancy

Attachment C: Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Description: Rule out intrauterine pathology and Screening for Fetal abnormalities

Attachment D: Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Description: First-trimester screening and Ovarian Dysfunction



Policy History

Revisions from 00.03.10e:
12/01/2017Physician Assistants (PAs) may be eligible to provide specific diagnostic ultrasounds to Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) members when rendered by specialists for services listed in Attachments A, B, C, and D.
Version Effective Date: 12/01/2017
Version Issued Date: 12/01/2017
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.