Commercial

Medical Policy

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:

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.

Title:

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

Policy #:

00.03.10F

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) specialist.

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 (e.g., 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 Benefit Contracts.

Coding

CPT Procedure Code Number(s)

Refer to Attachments A, B, C, and D

ICD - 10 Procedure Code Number(s)

N/A

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.03.10f:

09/25/2023

This version of the policy will become effective 09/25/2023. Policy number 00.03.10f is being issued to introduce a radiology capitation exception to allow specific obstectrical Ultrasounds reimbursement consideration by the Company when performed in the office setting by Nurse Midwife specialty, to rule out Ectopic Pregnancy, as identified in Attachment B of this policy.

Nurse Midwife provider type has been added to the following codes in Attachment B:

S8055, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817,

76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, 76999

In addition, the code set has been expanded to to allow OBGYN specialty to report the following OB ultrasounds & ecohcardio when performed in the office setting, as identified in Attachment B of this policy:

S8055, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76816,

76825, 76826, 76827, 76828, 76831, 76999

Revisions From 00.03.10e:

12/01/2017

Physician 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:

9/25/2023

Version Issued Date:

9/25/2023

Version Reissued Date: