CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Correction: Cervical length measurement by transvaginal ultrasound

Correction notice about billing and payment treatment when a transvaginal ultrasound is performed the same day as a routine anatomic evaluation ultrasound for MMC, HARP, CHPlus, and Essential Plan members.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyCorrection: Cervical length measurement by transvaginal ultrasound

Policy CodePolicy N/A

Change TypeClarified payment application and corrected codes

Effective Date2019-01-01 or as written

Next Review Date

Key ActionWhen billed same day by the same provider, pay transvaginal ultrasound (76817) at 50% and routine anatomic ultrasound (76801/76805/76811) at 100%.

SourceLink

POLICY UPDATE CHANGES

For claims on or after January 1, 2019, a transvaginal ultrasound billed the same day as a routine anatomic evaluation ultrasound by the same provider will be subject to multiple procedure reduction.

Correct CPT codes listed for routine anatomic evaluation ultrasound are 76801, 76805 and 76811; transvaginal ultrasound code is 76817.

50%payment reduction

3routine anatomic codes

1transvaginal code

Coverage Determination

Cervical length ultrasound payment rules

Payment determination when both routine anatomic and transvaginal ultrasound are billed same day by same provider:

When a routine anatomic evaluation ultrasound (76801, 76805, or 76811) and a transvaginal ultrasound (76817) are billed on the same day by the same provider, apply multiple procedure payment reduction so that the transvaginal ultrasound is paid at 50% of the applicable fee schedule and the routine anatomic evaluation ultrasound is paid at 100% of the applicable fee schedule.

This payment determination applies to claims submitted on or after January 1, 2019.

Applies to services administered to Medicaid Managed Care (MMC), Health and Recovery Plan (HARP), Child Health Plus (CHPlus), and Essential Plan members managed by Highmark BCBS in partnership with Wellpoint companies.

Relevant CPT Codes and Payment Details

Ultrasound CPT codes referencedCPT

76801	Abdominal ultrasound, obstetrical; single, first trimester
76805	Abdominal ultrasound, obstetrical; follow-up or repeat study
76811	Transabdominal ultrasound, pregnant uterus, real time with image documentation
76817	Transvaginal ultrasound, real time with image documentation

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyCorrection: Cervical length measurement by transvaginal ultrasound

Policy CodePolicy N/A

Change TypeClarified payment application and corrected codes

Effective Date2019-01-01 or as written

Next Review Date

Key ActionWhen billed same day by the same provider, pay transvaginal ultrasound (76817) at 50% and routine anatomic ultrasound (76801/76805/76811) at 100%.

SourceLink

On This Page

Billing and Provider Impact

Billing Rule

Multiple procedure payment reduction when transvaginal ultrasound is billed with routine anatomic ultrasound

When a routine anatomic evaluation ultrasound (CPT 76801, 76805, or 76811) and a transvaginal ultrasound (CPT 76817) are billed on the same day by the same provider, the transvaginal ultrasound will be subject to the multiple procedure payment reduction and paid at 50% of the applicable fee schedule; the routine anatomic evaluation will be paid at the full applicable fee schedule. This applies to claims submitted on or after January 1, 2019.

Applies when both procedures are billed the same day by the same provider.
Reduction percentage: 50% payment for the transvaginal ultrasound (76817).
Effective for claims submitted on or after 2019-01-01.

Procedure Definitions

Routine anatomic evaluation ultrasound (codes 76801, 76805, 76811)

Code 76801Abdominal ultrasound, obstetrical; single, first trimester (routine anatomic evaluation)

Code 76805Abdominal ultrasound, obstetrical; follow-up or repeat study (routine anatomic evaluation)

Code 76811Transabdominal ultrasound, pregnant uterus, real time with image documentation (routine anatomic evaluation)

Transvaginal ultrasound (code 76817)

Code 76817Transvaginal ultrasound, real time with image documentation; when necessary in addition to an abdominal scan to obtain cervical length measurement

Same-day billing ruleIf billed same day by the same provider as a routine anatomic evaluation (76801, 76805, 76811), 76817 is subject to multiple procedure reduction

Payment outcome76817 will be paid at 50% of the applicable fee schedule when reduced