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Re: 76811From: James Smeltzer (James.Smeltzer@wellstar.org)Mon Sep 26 12:45:15 2005
David, You are right! It is not fair! Everything you say makes sense, but the 76811 was a special code to pay people like you and me when we are doing prenatal diagnostic scans for specific (codeable) indications. When we find a problem on basic sonogram we either have them back if they cannot be done that day or convert it on site & use the dx plus 793.9. So far we get paid, but not a lot. We do undervalue our services & put up with a lot, but I do not know the solution. Medicaid here now precerts every exam over one for limited indications - so we debate the relative benefits of a NT scan vs targeted 20 wks plus cx. The work is still fun! Jim
>>> nyberg@u.washington.edu 9/25/2005 12:19:55 PM >>> 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:
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