CurrentFidelis CarePolicy FC.PP.009

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Defines Fidelis Care's payment rules when non‑obstetrical or first‑trimester obstetrical transabdominal ultrasounds are performed with transvaginal ultrasounds during the same patient encounter; applicable to providers submitting professional claims in office and institutional settings.

Policy Summary

PayerFidelis Care

PolicyNon-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Policy CodePolicy FC.PP.009

Change TypeMaterial revisions — payment percentage and reimbursement ordering clarified

Effective Date

Next Review Date

Key ActionSubmit a claim and reconfirm member eligibility at time of service; authorization does not guarantee reimbursement.

SourceLink

POLICY UPDATE CHANGES

Updated payment percentage for Medicare secondary procedure from '40% of' to '60% payment'.

Added paragraph stating that if a transabdominal image is unclear and a transvaginal ultrasound is necessary, only the transvaginal ultrasound will be reimbursed at 100% and the transabdominal will be reimbursed at the reduced secondary rate.

100%primary reimbursed

60%non‑Medicare secondary

50%Medicare secondary

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Payment and Billing Rules

Payment and Billing Criteria

When both a transvaginal and a transabdominal ultrasound are performed during the same patient encounter by the same provider or same group:

Transvaginal ultrasound is paid as the primary procedure at 100% of the fee schedule-allowed amount.

ALL of the following

Payment percentages
- Medicare: secondary transabdominal ultrasound reimbursed at 50% of the paid amount allowance.
- Non-Medicare: secondary transabdominal ultrasound reimbursed at 60% of the paid amount allowance.

If a transabdominal image is unclear and a transvaginal ultrasound is subsequently performed in the same encounter, only the transvaginal ultrasound will be reimbursed at 100% and the transabdominal ultrasound will be reimbursed at the reduced secondary rate (50% Medicare; 60% non-Medicare).

Multiple procedure payment reductions apply when services are furnished by the same physician or same group during a single patient encounter because most clinical labor activities are not duplicated for subsequent procedures (examples include greeting the patient, gowning the patient, preparing and cleaning the room).

This policy applies to non-obstetrical and first trimester obstetrical transabdominal ultrasounds performed with transvaginal ultrasounds and is applicable to providers submitting professional claims in office, institutional and non-institutional settings as specified by the Plan.

Authorization does not guarantee reimbursement; providers must submit a claim for services rendered and re-confirm member eligibility at the time of service.

CPT Codes and Payment Reductions

Referenced CPT codes for transabdominal and transvaginal ultrasoundsCPTCovered

76801	Ultrasound, pregnant uterus, real time image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach, single or first gestation
76817	Ultrasound, pregnant uterus, real time with image documentation, transvaginal
76830	Ultrasound, transvaginal
76856	Ultrasound, Transabdominal (non-obstetric), real time with image documentation; complete

Multiple procedure payment reduction percentages

Primary procedure reimbursementTransvaginal ultrasound reimbursed at 100% of the fee-schedule allowed amount.

Secondary procedure (Medicare)Transabdominal ultrasound reimbursed at 50% of the paid amount allowance when billed as the secondary procedure.

Secondary procedure (Non‑Medicare)Transabdominal ultrasound reimbursed at 60% of the paid amount allowance when billed as the secondary procedure.

Application when transabdominal image unclearIf the transabdominal image is unclear and a transvaginal ultrasound is subsequently performed in the same encounter, only the transvaginal is reimbursed at 100% and the transabdominal paid at the reduced secondary rate.

Authorization and Claims Submission Guidance

Documentation Required

Authorization and Claims Submission Guidance

Authorization does not guarantee reimbursement. To receive payment, providers must submit a claim for services rendered and reconfirm member eligibility at the time the service is rendered.

Definitions

Same Group Physician and/or Other Health Care Professional

DefinitionAll physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

ApplicationMultiple procedure payment reductions apply when services are furnished by the same physician or same group during a single patient encounter.

Billing implicationReductions are applied because most clinical labor activities are not duplicated for subsequent procedures performed by the same group.

Transvaginal Ultrasound

DefinitionTransvaginal ultrasound is an internal examination performed through the vagina to examine female reproductive organs including uterus, fallopian tubes, ovaries, cervix, and vagina.

ScopeUsed for evaluation of female reproductive organs; termed 'transvaginal' because it is performed through the vagina.