CPT code 76811 is for a detailed ultrasound exam of a single fetus, assessing anatomy and potential abnormalities during pregnancy.
CPT code 76811 is used for a detailed ultrasound examination of a single fetus during pregnancy. This code is typically applied when a more comprehensive evaluation is necessary, often due to specific medical indications or concerns. The detailed ultrasound includes an in-depth assessment of the fetal anatomy, which may involve examining the brain, heart, spine, and other vital structures to ensure proper development. This type of ultrasound is more thorough than a standard one and is often used to detect any potential abnormalities or complications.
When considering the use of CPT codes 76810 and 76811, it is important to determine if any modifiers are necessary to accurately reflect the services provided. Here is a list of potential modifiers that could be applicable:
1. Modifier 26 - Professional Component: This modifier is used when only the professional component of the service is provided. It indicates that the provider performed the interpretation of the ultrasound but did not own the equipment.
2. Modifier TC - Technical Component: This modifier is used when only the technical component of the service is provided. It indicates that the provider supplied the equipment and technical support for the ultrasound but did not perform the interpretation.
3. Modifier 59 - Distinct Procedural Service: This modifier may be used to indicate that a procedure or service was distinct or independent from other services performed on the same day. It is used to prevent bundling of services that are typically not reported together.
4. Modifier 76 - Repeat Procedure by Same Physician: This modifier is used when a procedure or service is repeated by the same physician or other qualified healthcare professional subsequent to the original procedure or service.
5. Modifier 77 - Repeat Procedure by Another Physician: This modifier is used when a procedure or service is repeated by a different physician or other qualified healthcare professional subsequent to the original procedure or service.
6. Modifier 78 - Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: This modifier is used if the procedure requires a return to the procedure room for a related procedure during the postoperative period.
7. Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period: This modifier is used when an unrelated procedure or service is performed by the same physician during the postoperative period.
8. Modifier 91 - Repeat Clinical Diagnostic Laboratory Test: This modifier is used when it is necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results.
These modifiers help ensure accurate billing and reimbursement by providing additional context about the services rendered. It is crucial to review payer-specific guidelines as they may have unique requirements for modifier usage.
Determining whether CPT code 76811 is reimbursed by Medicare involves consulting the Medicare Physician Fee Schedule (MPFS) and the guidelines set forth by the Medicare Administrative Contractor (MAC) specific to your region.
The MPFS provides a comprehensive list of services covered by Medicare, along with the corresponding reimbursement rates. However, coverage can vary based on local policies established by the MACs, which are responsible for processing Medicare claims and providing guidance on coverage specifics.
Therefore, to ascertain if CPT code 76811 is reimbursed by Medicare, it is essential to review the MPFS for the current year and consult with your regional MAC for any local coverage determinations or specific billing requirements.
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