Receiving denials when reporting 76811 with the advanced maternal age diagnosis
The SMFM Coding Committee received a recent inquiry regarding the usage of ICD-10 codes O09.512 and O09.522 when submitting charges after completing a 76811 exam on nulliparous and multiparous AMA patients in the second trimester. It was communicated that this family of ICD-10 codes used for this purpose are 'not acceptable as a principal diagnosis’ under the Medicare Code Editor (MCE). It was advised that based upon rules in the Official Coding Guidelines published by HHS, an alternative ICD-10 code should be used to support the 76811 CPT code in AMA patients regardless of the payer (even in the absence of payment denials). Is this an appropriate interpretation of coding guidelines?
We thank our SMFM members for notifying our SMFM Coding Committee about this issue. The committee was not aware that AMA (O09.51_ and O09.52_) codes are not being approved as appropriate indications for a 76811 by CMS/Medicare as per documentation in the MCE. The SMFM Coding Committee has a published list of what we consider appropriate indications for the performance of the 76811 based on the AIUM published practice parameter. The SMFM Coding Committee does not provide 'clinical guidance' - so we do not publish indications for the study but have translated them into ICD-10 codes for use within MFM practices. AMA is considered an appropriate indication for performance of a 76811.
When delving into this further, it was brought up that this may only relate to inpatient hospital coding (based on the verbiage “unacceptable principal diagnosis”) rather than outpatient (or provider) services. The SMFM Coding Committee will seek clarification on this issue with ACOG-CHEC who represents SMFM and other societies at the AMA/RUC level to assess whether this is regarding INPATIENT (principal diagnosis) facility only codes or both inpatient and outpatient services. We would also encourage our members to continue utilizing these codes with payors who allow this as an indication for 76811. If needed, an alternative solution would be to use the O35.8xx series as the primary code (maternal care for other (suspected) fetal abnormality) as this is the etiology/pathophysiology behind why we perform a 76811 in AMA patients. Most recent literature clinically supports that in addition to its association with aneuploidy, increasing maternal age is also independently associated with an increased risk for anomalies.