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Effective for dates of service September 1, 2011 and after, ultrasound procedures will no longer require authorization through the Radiology Benefit Management (RBM) program administered through ACS and MedSolutions Inc.
High-Tech, nuclear cardiac, and expanded cardiac imaging will continue to require authorization through the RBM program. An updated list of procedures requiring authorization will be available at http://www.medsolutions.com/implementation/mo_health/index.html.
Obstetric Ultrasound Policy for September 1, 2011 and After
With the removal of authorization requirements for obstetric (OB) ultrasound procedures, starting September 1, 2011 MO HealthNet will use the following policy.
Reimbursement is available for up to three OB ultrasound procedures during any one calendar year when reasonable and necessary based on medical indications. Ultrasounds provided in excess of three during any one rolling year must be submitted with a completed Certificate of Medical Necessity demonstrating appropriateness of use in proper diagnosing, management and treatment of pregnancy; including complicating, or potentially complicating conditions. Referring physicians are encouraged to provide information regarding the patient’s diagnosis for use by the billing provider.
Only one ultrasound is allowed per day. If it is medically necessary to perform a repeat ultrasound on the same day, refer to the CPT for follow-up or repeat procedure codes.
Failure of medical records to adequately document and support the utilization of ultrasonography procedures shall subject all payments made for these inadequately documented and unsupported services to recovery at the provider’s liability.
This policy of limitation applies only to program reimbursement that may be made for the service. It does not apply to the exercise of medical judgment by the attending physician as to need.