Re: 76811
From: Dave Berck (djberck@yahoo.com)
Mon Sep 26 08:48:34 2005
It also has the effect of perpetuating the generally poor quality of U/S done in the US by formalizing the notion of a "level I" scan. Aetna would rather have private offices with no expertise in ultrasound do poor quality scans than pay to have them done by people who do ultrasound for a living.
"art fougner, md" <evsono@pipeline.com> wrote:David
I second that emotion ... most fetal anomalies I've discovered were
found during a so-called "routine ultrasound." Would the presence of an
unsuspected anomaly justify a follow-up 76811? Or should the basic scan
be then expanded into a 76811?
Art
At Sun, 25 Sep 2005, David Nyberg wrote:
>
>How can anyone say that a woman age 35 or more deserves better care than a young under 35? Their incremental risk is small compared to the 2-3% risk of birth defects that every pregnancy carries. What constitutes risk, or high risk? 90% of birth defects are not chromosomal. 95% of birth defects have no family history or identifiable risk factors. For fetal Down syndrome, half of affected cases are to moms younger than age 35. If a couple is unfortunate enough to have a 2nd pregnancy with a birth defect, it is far more likely than it will be a birth defect unrelated to the first. All of this reflects the complexity of normal human development. It is a miracle that it happens at all.
>
>If you do adequate genetic counseling, you will find that many patients have a significant birth defect in the family history that the referring physician may not have been aware of. Also, if we find a fetal anomaly during the course of performing a 'basic' exam, does that mean we have to re-refer it for a detailed study? We see a lot of birth defects in my practice but at least half of these are ones we pick up during the course of routine screening- not referred because of suspected abnormalities. Many of these would be missed by a 'standard' survey performed by a general radiologist or obstetrician.
>
>A 2nd trimester fetal scan ALWAYS carries significant risk and responsibility, regardless of why the patient came for the scan. This takes time, effort, superior equipment, expertise, and risk. All of this requires money. There is no way to even break even with a 76805 reimbursement if you perform the detailed study that everyone deserves. The only way that makes any financial sense is if you have a very large volume as part of a bigger practice- for example, a busy radiology practice where the radiologist doesn't see the patient and the films pile up with standard x-rays. Or, for the general obstetrician who is making money on deliveries and clinical care, with incremental income from office ultrasounds. In both situations, the performing sonographer is almost always the one with any expertise, so they essentially they act unsupervised. That is one approach, and in many areas that may
>be all that is available. But, clearly there is a better approach and that should be reimbursed with a 76811 code. Having said that, I also know the 76811 code is sometimes abused. Those general radiology practices where the physician is not involved certainly should be using the 76805 code. Similarly, a general obstetrician should not be using the 76811 code.
>
>In my area, the reimbursement rates are not that much different, especially as a 'radiologist' who get inferior reimbursements to even general obstetricians. The 76805 code may reimburse about $130 and the 76811 is about twice that at Medicare rates, which seems to be the standard. We are not talking about a large difference in money, despite the large differences in how the exam is performed. In countries like Germany and Israel, the average reimbursement for a fetal survey is about $400 according to my colleagues, and this is what the government pays. In England, private scans go for about 400 pounds, not dollars. It is time the American insurance carriers adjust their prices for what is one of the most important events that occur during the entire pregnancy.
>
>The only choice some of have is to do the same detailed study on everyone, yet this policy would dictate that payment will vary with the preconceived reason the patient entered the room. That policy would be unique to radiology- certainly the reimbursement for CT and MRI does not vary with the reason, but rather what is performed. If everyone had a 2-3% chance of a brain tumor, do you think the insurance companies would not pay for routine MRI but would only pay for a non-contrast CT scan? How long would that last?
>
>Every patient should have the opportunity to have a thorough, detailed fetal anatomic survey, if they choose. Aetna and insurance carriers should recognize that and pay for that. Perhaps they will ask for a higher co-pay as a compromise.
>
>David
>
>The Fetal & Women's Center of Arizona
>http://www.fetalandwomens.com
>
>On Sun, 25 Sep 2005, Dave Berck wrote:
>
>>> From Josh Copel:
>>
>> There are 2 questions here and I'll try to address them both. First, full
>> disclosure: I am on the Maternal Fetal Medicine Foundation committee of the
>> Society for Maternal-Fetal Medicine, and I was on the committee that helped
>> develop the 76811 code.
>>
>> 1. The Maternal Fetal Medicine Foundation was set up recently by SMFM to
>> provide
>> NT education & ongoing quality monitoring in the US. It is based fully on the
>> standards of Kypros Nicolaides. It offers web based education and submission of
>> images for initial qualification. MFMF is working with the major private and
>> university labs to develop automatic submission of NT data from practices and
>> will provide quarterly feedback to sonographers and sonologists on how their
>> measurements compare with standards, so that "assay drift" in your measurements
>> can be identified. Anyone who is FMF(UK)-certified by Kypros Nicolaides' group
>> can sign up at no initial cost for a limited time. All money goes to a 501c3
>> not-for-profit corp. Information is available at .
>>
>> 2. The 76811 code is intended for pregnancies with identifiable risks for fetal
>> or genetic abnormalities (beyond the background risk inherent in all
>> pregnancies). I suspect that the Aetna is using ICD codes that are associated
>> with those risks (AMA, previously fetal anomaly), though I have no specific
>> information on the ICD codes they are accepting for reimbursing 76811. Now I
>> know this is not a popular position, but the 76811 code is not just for doing a
>> thorough scan, it is for those pregnancies with risks. Also, remember that
>> 76805
>> is not a limited scan, it is a basic fetal scan. This includes a fair amount of
>> anatomic evaluation, though remember there is also a different level of
>> liability for the two types of scan.
>>
>> Joshua Copel
>>
>> Orlando Ultrasound wrote:
>> Of those out there whom do insurance billing for fetal ultrasound exams (76811-full detailed fetal studies), what do you think of Aetna's reimbursement guidelines. They have taken statements from the maternal fetal medicine organizations and formed a reimbursement plan to pay for this code with a few distinct ICD codes. If those codes are not met then they will only pay for the limited 76805 exam/code. The lesser code only pays about 53% of the detailed exam.
>>
>> Is anyone in this ultrasiound scanning realm facing this issue, and what are you doing to circumvent this problem.
>>
>> Kevin
>>
>> Kevin Snider RDMS,RDCS,RVT
>> Chad Hall RDMS, RDCS, RVT
>> Orlando Ultrasound Associates, Inc.
>> Diagnostics - Consulting- Education
>> Office: (407)273-7303
>> Toll Free: (866)-613-7303
>> Fax (407) 381-2502
>>
>> To: Multiple recipients of list ULTRASOUND
>> Subject: Maternal Fetal Medicine Foundation
>> Date: Fri, 23 Sep 2005 21:16:07 -0500
>>
>> I have just been invited to join the Maternal Fetal Medicine Foundation and to give them money. They seem to be involved with quality assurance for NT measurements / 1st trimester screening. Does anyone have any experience with this organization? Who does my money go to? Why should I give them money to do something the FMF and NTD labs do for free? I'm trying to justify membership in yet another organization. Thanks.
>>
>> Dave Berck, MD, MPH
>>
>> David J. Berck, MD, MPH
>>
>> David J. Berck, MD, MPH
--
art fougner, md
"If you don't know where you are going, you will wind up somewhere else."
Lawrence Peter Berra
David J. Berck, MD, MPH
