Billing of 76801 and/or 76813 with cfDNA screening
Cell-free fetal DNA (cfDNA) screening has enhanced the ability to offer early aneuploidy screeningin pregnancy. The purpose of this White Paper is to describe billing recommendations when cfDNAscreening is done or considered in conjunction with first trimester Nuchal Translucency screening(CPT codes 76813 & 76814) and first trimester ultrasound studies (CPT codes 76801 & 76802).
What are the different CPT codes that may be considered?
CPT code 81420 (Fetal chromosomal aneuploidy genomic sequence analysis panel, circulating cellfreefetal DNA in maternal blood) reflects the identification of cell free fetal DNA in maternal serum toscreen for common fetal aneuploidies with high sensitivity and specificity. cfDNA provides a methodof non-invasive prenatal diagnosis and testing, most commonly trisomy 21, 18, and 13.
CPT codes 76813 and 76814 (first trimester fetal nuchal translucency measurement for singlegestation and each additional gestation) were established in 2007. These codes are used betweenten and fourteen weeks of gestation for the evaluation of the nuchal translucency as part of the firsttrimester genetic screening assessment.
Required elements of the 76813 ultrasound code include:
• Fetal crown-rump measurement
• Observation of fetal cardiac activity
• Observation of the embryo at high magnification until the embryonic neck is in a neutral positionand spontaneous embryonic movement allows for differentiation between the outer edge of thenuchal skin and the amnion
• At least three separate measurements of the largest distance between the inner borders of thefetal nuchal translucency
• Comparison of the largest nuchal translucency measurement from an acceptable image to crownrumplength and gestational age specific medians
• Written documentation of each component of the examination and permanent documentation ofultrasound images.2
CPT codes 76801 and 76802 are reported when the maternal and fetal ultrasound evaluation isperformed during the first trimester (< 14 weeks and 0 days for single gestation and each additionalgestation). These codes are indication-driven.
Required elements of the 76801 ultrasound code include:
• Evaluation of the presence, size, location, and number of gestational sac(s)
• The gestational sac is examined for the presence of a yolk sac and embryo/fetus.
• When an embryo/fetus is detected, it should be measured and cardiac activity recorded by a 2-dimensional video clip or M-mode imaging.
• The uterus, cervix, adnexa, and cul-de-sac region should be examined.
• Written documentation of each component of the examination and permanent documentation ofultrasound images.
The only indication for performing the 76813 and 76814 examinations is to measure the fetal nuchaltranslucency as one component of screening for fetal aneuploidy (i.e., first trimester ultrasoundscreening, first trimester combined ultrasound and maternal serum screening, combined first andsecond trimester sequential screening, combined first and second trimester integrated screening).When this study is performed for screening but without another specific indication (e.g. advancedmaternal age, etc.), the appropriate diagnosis code that should be linked to this study would be Z36(Other specified antenatal screening).
SCENARIOS
Scenario 1: Patient is already planning to do cfDNA testing or with known cfDNA resultsIn women who have already received reassuring negative cfDNA screening results, an additionalultrasound at 10-14 weeks of gestation solely for the purpose of NT measurement (CPT codes76813/76814) is not recommended. Therefore 76813/76814 should not be usually billed even if theNT measurement is obtained.However, with positive cfDNA screening results or if an indication is present to evaluate the fetusand/or mother in the first trimester, including an indication to evaluate the embryo anatomy, then it isappropriate to bill 76801 (add 76802 for each additional gestation) as well, as long as the requiredelements of each code are obtained.If an E/M service is performed during the same encounter as the ultrasound, other than to explainthe risks and benefits of the procedure, it would be appropriate to bill the appropriate E/M service inaddition to the procedure, as long as all the elements of the E/M are also met. Modifier -25 may needto be attached to the E/M service to indicate it is a separately identifiable service from theprocedure(s).
Scenario 2: Patient presents for NT screening without prior cfDNA performed.The NT is requested by the referring provider and the elements of 76813 are obtained by the MFM.76813 is appropriately billed. If the same or another MFM discusses genetic options, including cfDNAwhich is then offered after the ultrasound examination, the corresponding Evaluation andManagement (E/M) would then be appropriately billed. Modifier -25 may need to be attached to theE/M service to indicate it is a separately identifiable service from the ultrasound procedure.76801/76802 may also be billed if an appropriate and separate indication is present for that.
REFERENCES
1. Society for Maternal-Fetal Medicine (SMFM) with the assistance of Mary E. Norton, MD; JosephR. Biggio, MD; Jeffrey A. Kuller, MD; Sean C. Blackwell, MD. Consult Series # 42: The role ofultrasound in women who undergo cell-free DNA screening. Am J Obstet Gynecol 2017;216:B2-B7.2. American College of Obstetricians and Gynecologists. Screening for fetal aneuploidy. ACOGPractice bulletin # 163. Obstet Gynecol 2016;127:e123-37.3. American College of Obstetricians and Gynecologists. Cell-free DNA screening for fetalaneuploidy. ACOG Committee opinion # 640. Obstet Gynecol 2015;126:e31-7.4. Society for Maternal-Fetal Medicine (SMFM) Publications Committee. Consult Series # 36:Prenatal aneuploidy screening using cell-free DNA. Am J Obstet Gynecol 2015;212:711-6.5. Society for Maternal-Fetal Medicine (SMFM) Publications Committee. SMFM statement:clarification of recommendations regarding cell-free DNA aneuploidy screening. Am J ObstetGynecol 2015;213:753-4.