May 8, 2012
On April 24, 2012, Aetna updated Clinical Policy Bulletin (CPB) #0106 for fetal echocardiograms. If you render any maternal-fetal services, or likewise do the medical billing for any speciality that accepts commercial insurance, you should make yourself familiar with Aetna’s Clinical Policy Bulletins. These CPB’s clearly define Aetna’s standards regarding medical necessity and services that fall within the category of experimental and/or investigational billing. The CPB’s outline the medical literature that supports the status determinations, and offers a complete table of CPT’s and ICD-9’s that are covered. Prior to rendering any services, a medical billing and coding expert should consult with the provider to discuss the medical conditions and diagnoses that warrant medically necessary procedures, per Aetna’s policies. In the absence of a supporting diagnosis, the provider should be made aware that claims can deny for experimental/investigational billing. To ease this process, providers should familiarize themselves with the lists of ICD-9’s that specifically support the billing of particular CPT’s. At the present, we draw your attention to Aetna’s CPB on fetal echocardiography. This CPB was recently updated to expand the indications of medical necessity for fetal echocardiograms. These new indications include: autoimmune antibodies associated with congenital heart disease, familial inherited disorders (e.g. Marfan syndrome) associated with congenital heart disease, monochorionic twins, multiple gestation and suspicion of twin-twin transfusion syndrome, or teratogen exposure; and indications of fetal extra-cardiac anomaly, hydrous, or unexplained severe polyhydramnios. CPT’s affected by this revision include 76825, 76826, 76827, and 76828. For the complete list of supported ICD-9’s, please view the complete CPB on Aetna’s website.
Again, each of Aetna’s CPB’s are publicly-accessibe on their website. The CPB’s cover medical procedures that span across all specialities. As always, the provider should use his or her own professional judgment when determining the appropriateness of medical procedures and the treatment of each patient.
(Source: Aetna Clinical Policy Bulletin: Fetal Echocardiograms #0106, Last Review 04/24/2012).