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Erroneous Payment of CPT-4 Codes Billed with Pregnancy-Related ICD-10 Codes

January 26, 2016

The Department of Health Care Services (DHCS) has identified a claims processing issue that may cause claims billed with pregnancy-related ICD-10-CM codes A34, O00.0 – O9A.53, Z33.1 – Z36, or Z64.0 – Z64.1 to erroneously reimburse when billed with one of the following CPT-4 codes:

CPT-4 Code Description
76830 Ultrasound, transvaginal
76856 Ultrasound, pelvic, real time with image documentation; complete
76857    limited or follow-up
93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
93976    limited study

CPT-4 codes 76830, 76856 and 76857 (non-obstetric sonography procedures), and codes 93975 and 93976 (duplex scan of arterial/venous flow) are not reimbursable if billed in conjunction with ICD-10-CM codes A34, O00.0 – O9A.53, Z33.1 – Z36, or Z64.0 – Z64.1. Updated manual pages reflecting these changes will be released with a future Medi-Cal Update.

This issue affects claims for dates of service on or after October 1, 2015. DHCS will notify providers when the issue is resolved. Affected claims will be reprocessed via an Erroneous Payment Correction (EPC). Providers should continue to submit claims in a timely manner. Providers are encouraged to check the Medi-Cal website regularly for updates regarding this issue.