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Date: January 10, 2020
To: Health Plan of San Joaquin (HPSJ) OB/GYN Offices/Groups, Clinics, and FQHC’s
From: HPSJ Claims Department
Subject: Update – Possible Fraud, Waste and/or Abuse (76811 vs 76805)

  • CPT Code 76811, Detailed Fetal Anatomic Ultrasound
  • CPT Code 76805, Complete OB Ultrasound 
Business: Medi-Cal Managed Care

In accordance with the California’s Department of Health Care Services (DHCS) All Plan Letter (APL) 17-003, Health Plan of San Joaquin (HPSJ) has implemented new auditing algorithms to identify potential overpayments or incorrect payment practices resulting in possible Fraud, Waste and/or Abuse (FWA). 

CPT Code 76811, Detailed Fetal Anatomic Ultrasound

In a recent internal audit, HPSJ identified misuse and/or overuse of CPT Code 76811, Detailed Fetal Anatomic Ultrasound.  

To ensure providers are appropriately ordering the Detailed Fetal Anatomic Ultrasound, please review the following.

When is a Detailed Fetal Anatomic Ultrasound appropriate?

The detailed fetal anatomic examination (76811) is not intended to be the routine ultrasound examination performed for all pregnancies.  Rather, it is an indicationdriven examination performed for known or suspected fetal anatomic abnormality, known fetal growth disorder, genetic abnormality, or increased risk for a fetal anatomic or genetic abnormality. Thus, the performance of the detailed fetal anatomic examination should be rare, carried out by outside referral practices with special expertise in the identification and diagnosis of fetal anomalies. 

Who should be performing Detailed Fetal Anatomic Ultrasounds?

Performance and interpretation of a Detailed Fetal Anatomic Ultrasound requires advanced skills and knowledge, with the ability to effectively communicate the findings to the patient and their referring physician.  The detailed anatomic scans of the fetus are optimally performed in facilities that are accredited in ultrasound by organizations such as the American College of Radiology (ACR) and American Institute of Ultrasound in Medicine (AIUM). 

What are the common indications for ordering Detailed Fetal Anatomic Ultrasounds?

Indications for a detailed fetal anatomic ultrasound include, but are not limited to, the following conditions:

    • Previous fetus or child with a congenital, genetic, or chromosomal abnormality
    • Known or suspected fetal anomaly or known growth disorder in the current pregnancy
    • Fetus at increased risk for a congenital anomaly, such as the following; o Maternal pregestational diabetes or gestational diabetes diagnosed before 24 weeks gestation
      • Pregnancy conceived via assisted reproductive technology o High maternal body mass index (>/= 35kg/m2)
      • Multiple gestations
      • Abnormal maternal serum analytes, including a-fetoprotein level and unconjugated estriol
      • Teratogen exposure
      • First-trimester nuchal translucency measurement of 3.0 mm or greater
    • Fetus at increased risk for a genetic or chromosomal abnormality, such as the following; o Parental carrier of a chromosomal or genetic abnormality o Maternal age of 35 or older at delivery
      • Positive screening test results for aneuploidy, including noninvasive prenatal testing
      • Soft aneuploidy marker noted on an ultrasound examination o First-trimester nuchal translucency of 3.0 mm or greater
    • Other conditions affecting the fetus, including the following; o Congenital infections o Maternal drug dependence o Isoimmunization o Oligohydramnios
      • Polyhydramnios

CPT Code 76805, Complete OB Ultrasound 

The more routine ultrasound, Complete OB Ultrasound (76805), is commonly performed at approximately 16-20 weeks gestation requiring components such as Head & Neck, Face, Chest, Abdomen, Spine, Extremities, Placenta, Standard Evaluation, Biometry and Maternal Anatomy

When referring a patient for Obstetric Ultrasound, proper diagnosis with detailed indicators for radiologists will help reduce unnecessary exams.   

If you have questions, please contact our Customer Service Department at 209-942-6320.

Posted on March 2nd, 2020 and last modified on March 2nd, 2020.