All PlansCoverageHigh impact
Reimbursement Policy Updates: Effective November 1, 2020
Healthfirst·OB-GYN, Radiology·Provider Update
Effective date
Nov 1, 2020
We identified it
Jun 20, 2026
Summary
Healthfirst will no longer reimburse certain ultrasound procedures when billed together, considering them redundant services. CPT 76817 (transvaginal ultrasound) cannot be billed with transabdominal obstetric ultrasounds (76801-76812), and CPT 76856/76857 (pelvic ultrasound) cannot be billed with CPT 76830 (transvaginal ultrasound). Additionally, repeat obstetric ultrasounds within 5 months will be recoded to follow-up ultrasound CPT 76816.
Action Required
By November 1, 2020: Billing team must update system edits to prevent billing CPT 76817 with codes 76801-76812, and prevent billing CPT 76856/76857 with CPT 76830. Configure automatic recoding of repeat obstetric ultrasounds (76805, 76810-76812) to CPT 76816 when initial study billed within previous 5 months. Update encounter forms to alert providers about redundant ultrasound restrictions. Claims for these code combinations will be denied.