Payors covering one complete ultrasound; other exams coded separately

Q.

I am finding that payors will not cover CPT code 76805 if CPT 76801 has already been billed. Do you know why that is?

A.

Many insurances will only pay for one complete ultrasound. After a complete ultrasound has been done, other exams are considered follow-up or limited exams and would be billed with either CPT code 76815 or 76816.

As stated in the Spring 2019 issue of Clinical Examples in Radiology, “Code 76816 is reported if a complete examination is performed to reassess fetal size, interval growth, or previously demonstrated anatomic abnormalities.” Follow-up code 76816 is reported regardless of whether the fetus is younger than 14 weeks 0 days or older than or equal to 14 weeks 0 days. It should be reported for each fetus after the first fetus that requires reevaluation, with modifier 59 appended to indicate separate and distinct procedures.

That issue of Clinical Examples in Radiology also states, “When an obstetrical ultrasound procedure is performed for limited purposes (e.g., fetal viability, fetal position, or amniotic fluid volume), code 76815 should be reported once per examination; it should not be reported per element or per fetus.”