Wiki Help

[TYSON1234]

Anybody else having problems with BCN paying for more than u/s (code 76805).
Pt had u/s done on 9/16 to confirm her pregnancy, on 10/7 she had another one for 20 week and then on 10/21 for a follow up due to fetal abnormality. BCN is denying stating the clinical editing rules define the procedure code, modifier or place of service as inappropriate for the reported service. I called BCN informed them there's no modifier on the claim, and they stated they would resend the claim to the correct department. I just received another RA and it states the same thing. I called them again and this time they couldn't help me out. I've never had to put a modifier on any of my claims for u/s. Any suggestions would be appreciated.

Thanks

 

[Emmy1260]

The US on 10/21 probably needs to be 76816 not 76805. 76816 is a follow-up US for re-evaluation of organ systems(s) suspected or confirmed to be abnormal on a previous scan.

If the US on 10/7 is also being denied, look at the reason it was ordered. Often this 20 week is to confirm due date/size/etc. in which case 76815 US limited is appropriate. Was a "detailed fetal anatomic exam" documented, in which case 76811 may be appropriate. 76805 is a comprehensive US and has specific documentation requirements as well.

A review of each US report should lead you to more appropriate code selection.

 

[TYSON1234]

Thank you for the advice. The only problem I have is, back in July, according to the Ob-Gyn Coding Alert, 76811 is a second level u/s performed on a high resolution u/s used by MFM. We're to use the code 76805.