Maternal-fetal medicine billing is slightly different than billing for a regular pregnancy patient. Many procedures have a unique set of billing codes that might be confusing for medical offices. Generally, most services performed on the mother to check on the health of the baby after eight to 12 weeks of gestation and 30 to 45 days after delivery can qualify as maternal-fetal medicine, or perinatology.
Obstetrical codes range between 76801 and 76828 and include various procedures like basic ultrasound, Doppler velocimetry, and echocardiography of the fetus. By learning what procedures fit into these codes, offices can create accurate bills that will be accepted by insurance companies.
How to Code an Ultrasound
In order to effectively bill an ultrasound, providers need to include both a written report as well as an image. However, when billing, coders can enter separate codes for the complete scan, just the image, or just the findings of the scan. It all depends on the purpose and the results of the scan.
For codes that include a plus sign before the start of the CPT code, billing professionals cannot use a 51 modifier, as the plus sign signifies an add-on code. In most cases, the add-on code in this case is used to designate each additional gestation, which is appropriate for when the mother is pregnant with more than one fetus at a time.
Generally, an ultrasound can be recorded under the 76801, 76802, 76805, 76810, 76811, or 76812 CPT codes. To use 76801, it's important that the doctor makes note of the required visible elements that are appropriate for gestation and listed specifically in the CPT code book. Additionally, 76801 is generally used in the first trimester.
After the first trimester, most ultrasounds qualify for the 76805 code. To code for this, a billing provider will also need the number of gestations as well as results from the examination of the maternal adnexa. Because the fetus has developed since the first trimester, measurements like head diameter, circumference, and femur length are also essential. To get reimbursed for this code, all of these elements and more will need to be documented. If they aren't, there will need to be a reason listed for why the information was not collected.
If even more detail is collected than necessary during a routine second or third trimester ultrasound, it might qualify as a 76811. This extra detail can come in the form of abdominal organs, brain, face, heart, or umbilical cord evaluation. Typically, this ultrasound is not a routine procedure and is only done when there is a suspected genetic abnormality or other issue. Generally, it is only performed by practitioners who have advanced expertise in identifying fetal problems.
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In each of these three codes, if an additional gestation is involved, then the companion codes of 76802, 76810, and 76812 can be used to document the additional ultrasound.
Additional Fetal Screenings
Traditional ultrasounds aren't the only thing involved in maternal-fetal medicine billing. For example, 76813 is the code for nuchal translucency screening, a type of ultrasound that is performed between 11 and 14 weeks to provide a more in depth look at the fetus. In this test, providers will need to document the fetal viability, crown-rump measurement, and nuchal thickness.
The code 76820 is used for a Doppler umblicial scan. This is a rare procedure only done in pregnancies where intra-uterine growth restriction or twin-to-twin transfusion syndrome might be causing problems.
Other codes of note include 76821 for Doppler cerebral artery scanning, 76825 for fetal echocardiograms, and 76827 for Doppler echocardiography.