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December 2016 Texas Medicaid Provider Procedures Manual

Gynecological, Obstetrics, and Family Planning Title XIX Services Handbook : 3 Obstetric Services : 3.1 *Services, Benefits, Limitations, and Prior Authorization : 3.1.7 Obstetric Ultrasound

3.1.7
The following procedure codes may be submitted for obstetric ultrasound services:
 
Texas Medicaid requires providers to follow the documentation requirements as set forth in the Diagnostic Ultrasound section of the Current Procedural Terminology (CPT) manual for the diagnostic studies of the fetus, including when ultrasound is used to guide a procedure.
Documentation requirements set forth in the CPT manual include, but are not limited to:
Permanently recorded images are also required for ultrasound guidance procedures of the site to be localized. In addition, description of the localization process, either separately or within the report of the procedure when the guidance is utilized.
Permanently recorded images must be available on request by the Texas Health and Human Services Commission (HHSC).
Prior authorization is required for greater than three obstetrical ultrasounds per pregnancy. Requests for additional obstetric ultrasounds may be considered when submitted with documentation of medical necessity on the Obstetric Ultrasound Prior Authorization Request Form.
Refer to:
Authorization is not required for obstetric ultrasounds performed in the emergency department, outpatient observation, or inpatient hospital setting.
Texas Medicaid follows the American Congress of Obstetricians and Gynecologists (ACOG) indications for sonography.
First trimester ultrasounds may be medically necessary for, but not limited to, the following conditions:
Second- and third-trimester ultrasounds may be medically necessary for the following conditions:
A request for retroactive authorization must be submitted no later than 14 calendar days, beginning the day after the study is completed.
Requests for prior authorization or retroactive authorization may be submitted by phone, mail, or an approved electronic method.
The Obstetric Ultrasound Prior Authorization Request Form must be completed, signed, dated, and maintained in the client’s medical record by the provider requesting the test. The form must include information related to medical necessity of the test including all of the following:
Additional documentation to support medical necessity may include any of the following:
The Obstetric Ultrasound Prior Authorization Request Form must be completed, signed, and dated by the ordering provider (physician, nurse practitioner/clinical nurse specialist, certified nurse midwife [CNM], or physician assistant) when requesting prior authorization for obstetric ultrasounds, regardless of the method of request for authorization.
Residents may order obstetric ultrasounds; however, the attending physician must sign the authorization form and provide the group or supervising provider’s provider identifier.
Providers may be requested to provide additional documentation.
Obstetric ultrasounds provided in the emergency department or outpatient observation must be submitted with Modifier U6 when submitted on the professional claim form in order to be considered for reimbursement.
Obstetric ultrasounds provided in the emergency department or hospital observation must be submitted with the appropriate corresponding emergency services or hospital observation revenue code in order to be considered for reimbursement.
Note:
Any obstetric ultrasound claims submitted with or without prior authorization for the initial three will count toward the limit of three per pregnancy.
For transvaginal obstetric ultrasound performed in addition to one of the transabdominal examinations, documentation is required to substantiate the need to perform both tests on the same day.
Reimbursement for obstetric ultrasounds may be considered on appeal when submitted with documentation of any one of the following:
Only one appeal will be considered per client for the same provider. Providers must obtain prior authorization for additional obstetric ultrasounds performed after the appealed service.
Add-on procedure codes (76802, 76810, 76812, and 76814) when billed with the primary procedure code for obstetric ultrasounds do not count toward the limit of three per pregnancy.
Claims for add-on codes for multiple fetuses should be billed with Modifier 76 if greater than one additional fetus. Claims for multiple fetuses greater than two will be considered on appeal with documentation indicating number of fetuses.
Three dimensional (3-D) rendering of obstetric ultrasound (procedure code 76376 or 76377) is not a benefit of Texas Medicaid.
Procedure code 76810 must be billed in conjunction with primary procedure code 76805, any provider.
Procedure code 76812 must be billed in conjunction with primary procedure code 76811, any provider.
Procedure code 76814 must be billed in conjunction with primary procedure code 76813, any provider.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.