Wiki Help with NT study 76801

MFMcoder

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Hello - I am needing help with an audit that says I should bill a 76815 instead of a 76801 with a 76813 for an NT study. Is there any resources out there that can help me?
 
Hello - I am needing help with an audit that says I should bill a 76815 instead of a 76801 with a 76813 for an NT study. Is there any resources out there that can help me?
Do you mean NST? If so it would be 59025. I work in the OB triage and following listed are the most CPT codes we use for US.

US ABD for pregnancy:
76801 less than 14 wks.
76805 more than 14 wks.
76815 bedside or limited
76817 Transvaginal US
 
It would depend what's documented in the report. Is it just for the NT? We normally see 76801/76813.
If the ultrasound meets all the components for 76801, then bill that. If not then 76815.
 
Hello - I am needing help with an audit that says I should bill a 76815 instead of a 76801 with a 76813 for an NT study. Is there any resources out there that can help me?
In order to bill both 76801 and 76813 you need to have both separately documented. If the only purpose of the exam was for the nuchal translucency then you only bill 76813 and this code is used whether the ultrasound is done vaginally or abdominally. 76815 is for a single quick measurement and would not be appropriate for a complete abdominal ultrasound (and documented as such) with NT study. You need to look at the documentation and then appeal the finding if you have met the requirements for both codes.
 
We also are looking for some help with billing 76815 with 76813. Report shows transabdominal ultrasound with measurements for CRL, Cervix Length, FHR, and NT. I am trying to find documentation what is needed for the NT study and since the FHR and Cervix Length were also done would this support the 76815 to be billed with the 76813? Also, would we need a 59 modifier on the 76815 if able to bill them both
 
We also are looking for some help with billing 76815 with 76813. Report shows transabdominal ultrasound with measurements for CRL, Cervix Length, FHR, and NT. I am trying to find documentation what is needed for the NT study and since the FHR and Cervix Length were also done would this support the 76815 to be billed with the 76813? Also, would we need a 59 modifier on the 76815 if able to bill them both
So a nuchal scan, as represented by CPT code 76813, includes only the measurement of the nuchal fold. That is, your documentation should show that the transducer was oriented on the neck area of the fetus and that 3 measurements were taken of the amount of fluid present (they use the largest measurement) but then must compare that to crown-rump length and gestational age. This diagnostic screening test is done to detect possible chromosomal abnormalities such as Down’s Syndrome and is only a meaningful measurement if performed prior to 14 weeks gestation because the fluid is absorbed as the fetus grows. The crown-rump length is not measured as an integral part of the NT work for which the code was valued under the relative value system and in fact a previous ultrasound result (for instance is they did first trimester screening a few days before) can be used.

But frequently, the NT scan that the first trimester scans are done at the same time and so it is appropriate to bill both 76813 (plus 76814 if multiple pregnancy) and 76801 (plus 76802 if multiple pregnancy) at the same session. CPT guidelines makes this clear if you look at the note following 76801 which says “to report a first trimester fetal nuchal translucency measurement, use 76813.” This note represents an “excludes” notation in that it says that 76813 is not included in 76801. The required key elements for billing 76801 includes documenting the number of membranes and placentas and type of zygote, fetal measurements (like crown-lump length and fetal heartbeat), a survey of any visible fetal anatomy, an assessment of the umbilical cord and placenta when visible, qualitative assessment of the amniotic fluid volume (it is not a calculated value as would be done in the 2nd trimester – just a look to see if it appears to be too much or too little or normal), and evaluation of maternal uterus and adnexa.

The code 76815, on the other hand, represents a quick clinical look of one or more of the elements listed in the code description (which refers to one of more of the following: fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume). So the bottom line is that you MUST read the documentation to choose the correct code. If the provider does not evaluate the adnexa and uterus, this would be a reason for the payer to deny code 76801 when presented with the documentation. If there is mention of these structures, then 76801 and not 76815 is the correct code. But also note that 76815 DOES NOT include the crown-rump measurement. These are points that should be discussed with your providers if your documentation is too vague to ensure they get paid the higher valued code in addition to the NT.

As to the documentation of cervical length: per SMFM this is a measurement that should be done between 18 and 24 weeks, not in the first trimester of pregnancy. However, as the code 76801 does require an exam of the uterus ( and the cervix is attached), this measurement could be considered documentation of that requirement for 76801, but not 76815. Interestingly, 76801 and 76813 are not bundled, but 76813 and 76815 are (but allow use of the modifier -59). This tells me that Medicare (the entity that assigns the bundles), has very little understanding of what an NT measurement was valued to include. So yes, you would have to use a modifier -59 on code 76815 when billed with 76813. Hope this long and detailed explanation helps.
 
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