Erroneously Denied Ultrasound Claims Will Be Reprocessed
The Department of Health Care Services (DHCS) identified a claims processing issue causing some ultrasound claims to erroneously deny when billed with CPT-4 codes 76813 (ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation) and 76814 (…each additional gestation), along with ICD-10-CM diagnosis code Z36 (encounter for antenatal screening of mother).
An update to resolve this issue was initially implemented on April 11, 2016; however, post-implementation analysis indicated that some claims were continuing to erroneously deny. Additional corrective action has been taken to resolve these residual issues.
Affected claims will be reprocessed via an Erroneous Payment Correction (EPC) as follows:
- Claims erroneously denied from October 1, 2015, through April 11, 2016, will be reprocessed no later than July 15, 2016.
- Claims erroneously denied on or after April 11, 2016, will be reprocessed no later than May 31, 2016.
No action is required of the provider. 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.