Re: 76811
From: James Smeltzer (James.Smeltzer@wellstar.org)
Mon Sep 26 13:10:55 2005
Art, Either works depending on your schedule and sonographic
constraints.
>>> evsono@pipeline.com 9/26/2005 8:28:36 AM >>>
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
<http://www.mfmf.org>.
>>
>> 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 <orlandoultrasound@hotmail.com> 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
<ultrasound@dns.obgyn.net>
>> 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
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