Pregnancy: Early Care & Diagnostic Services
| Date: | December 15, 2016 |
| To: | Health Plan of San Joaquin (HPSJ) Providers |
| From: | HPSJ Medical Management Department |
| Subject: | Pregnancy: Early Care & Diagnostic Services |
| Business: | Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM) |
Health Plan of San Joaquin (HPSJ) strives to maintain, update and educate on the guidelines set forth by Medi-Cal (MCAL), while continually seeking ways to streamline processes. We believe the following will be helpful for your practice.
Per MCAL guidelines, Ultrasound/Diagnostic services are reimbursable as follows:
- Diagnosis on the claims must be appropriate for the code as defined on the MCAL chart for “Pregnancy: Early Care and Diagnostic Services” of the MCAL guidelines
- Frequency must meet the restrictions as defined in “Pregnancy: Early Care and Diagnostic Services” of the MCAL guidelines
- Some CPT codes must have the justification provided in the Remarks field (Box 80) of the UB-04/Additional Claim Information field (Box 19) of the HCFA 1500 claim form to support medical necessity, as outlined in the “Pregnancy: Early Care and Diagnostic Services” of the MCAL guidelines.
Fetal echocardiography & Doppler echocardiography/velocimetry
HPSJ requires these:
- Must be billed with the referring OB referral/orders indicating what codes and/or tests are to be performed – Effected codes are: 76820-76821 and 76825-76828
- Include the referral and supporting OB documentation with submitted claims
When providers are referring for these types of services, we request that their referral include the exact diagnostic test they are requesting and reflect the guidelines listed above.
For more information and tips on billing –
Please refer to the MCAL website http://www.medi-cal.ca.gov under “Pregnancy: Early Care and Diagnostic Services.”
If you have any further questions, please contact our Provider Services Department at 209-942-6340.