Wiki down coding from 76811 to 76805 for MFM

[smlavi]

I have a question regarding coding 76811 versus 76805 for MFM. there has been question in our clinic....
1) For our clinic, being a specialty clinic, we automatically perform a level II full fetal anatomy Ultrasound 76811 on our patients, unless; of course they are under 18 weeks gestation... but if they have just anatomical scan with no other diagnostic reason for that scan, we bill for a 76805 instead even though the report shows we performed the 76811. could that be billed correctly as 76805 with diagnosis code Z36.89?
2)If the fetus ends up being large for dates, (O36.69X0) where the fetus measures at 90% or greater, my Doc feels that is not adequate to bill a 76811 with LGA diagnosis and should code a 76805 instead. Is LGA diagnosis (O36.369x0) a reasonable DX to bill with 76811?

I could use some input regarding these 2 questions.

thank you,

Sheila

 

[thomas7331]

MFM is not a specialty I know well but I'll just make a general comment that I think you can get into trouble if you're not coding and billing what was performed. It isn't appropriate to 'down code' or code a different service than what the record shows was actually performed just to try to ensure that you get payment from your payer. Whether or not a diagnosis is 'adequate' for a particular procedure is a coverage decision that a payer is going to make and it isn't up to the physician to bill something different because they suspect the diagnosis might cause the insurance not to pay.

The physician should order the test that they think is appropriate to diagnose and treat their patient. If there's a concern about the diagnosis not supporting the procedure, then your practice should contact the patient's plan in advance to find out if it will be covered, not just change to a lower level code - that would be fraudulent. In the event that the procedure isn't covered, the physician should have a discussion with the patient as to whether or not they want to proceed with the procedure and pay out of pocket, or else opt for a different procedure.

 

[Mnmark442]

Hi,

76811 is for a high risk patient. Although that may qualify a patient to see MFM and is considered a high risk problem, I would still code 76805 (especially if Dr is ordering that).

How I simplified this for myself when I was learning: If the patient is high risk the entire pregnancy (example: patient with uncontrollable diabetes or autoimmune disease that can effect pregnancy) then 76811 would qualify.

If the issue at hand becomes an unresolved, constant issue, then it could qualify for high risk (76811) as well.

Lastly, if the provider is ordering and performing the 76805, then you must code as such, regardless.

Hope this helps : )

 

[PFLOOD]

I have a question in regard to the down coding of 76805. I've seen that you must down code to 76815 if all elements are not mentioned in 76801. What do you change the code to if all elements are not mentioned in 76805? Would it still be 76815?