Medical necessity and documentation requirements for obstetric ultrasound plus nuchal transparency (NT) screening

Q.

I have a question regarding the obstetric ultrasounds we do. The exam charge is entered into the system by the technologist performing the exam. We have been seeing a lot of instances where one exam is being selected/billed but the actual reports document not only that exam, but also the documentation requirements are met for another exam. For example, a patient comes in for a nuchal translucency (NT) screening, and the report documents the NT but also documents everything for a first-trimester scan. We’re questioning if it is acceptable practice for us to add the charge for the additional exam in these scenarios or does that need a specified order from the referring provider?

A.

There needs to be an order. In the hospital, that can be from the radiologist if they feel it is necessary for the individual patient to do the additional exam. If they do, they need to document their intention to do the additional exam and why it is necessary. If you don’t have an order from either the referring physician, or the radiologist doesn’t document the intent and medical necessity for an additional exam, it should not be reported.

If this is just being performed simply because your protocol is to do a full OB US when you perform a nuchal translucency measurement, then you should only code for the NT exam.

If you charge for an OB US with every NT exam, you will raise flags, and eventually, most likely be audited. Even though these are not likely to be Medicare patients, other payors also have fraud units and do audits.