Provider Alerts

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Date:	July 10, 2024
From:	Health Plan
To:	Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Obstetric Care Providers and Diagnostic Radiologists
Type:	Regulatory
Subject:	Ultrasound During Pregnancy
Business:	Medi-Cal Managed Care

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Please review the following Medi-Cal (MCL) billing guidelines for proper claim submission and reimbursement for ultrasound during pregnancy services.

Ultrasound During Pregnancy

An ultrasound performed for routine screening during pregnancy is considered an integral part of the patient’s care during pregnancy and its reimbursement is included in the obstetrical fee. Ultrasound during pregnancy is separately reimbursable only when used for the diagnosis or treatment of specific medical conditions.

Diagnosis, Frequency and Documentation Guidelines

Ultrasound services are reimbursable as defined below:

• Diagnosis on the claim must be appropriate for the CPT code being billed
• Frequency must meet the restrictions listed
• Some claims must have documentation in the Additional Claim Information field (box 19) on the claim to justify medical necessity.

Claims billed with CPT Codes 76813 and 76814 requires documentation submitted with the claim that states: The physician performing or supervising the ultrasound is credentialed by either the Nuchal Translucency Quality Review program or the Fetal Medicine Foundation.

For additional information related to ultrasound billing during pregnancy please see pages 19-27: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/09FC6B68-5741-4478-B087-2D8CA5DBAC25/workbook_ob_hap.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO

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If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG