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00.03.10f, Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
Effective date
Sep 25, 2023
Identified
Jun 19, 2026
Summary
This policy reissue (effective 09/25/2023) introduces a radiology capitation exception allowing Nurse Midwives to bill specific obstetrical ultrasound codes when performed in-office to rule out ectopic pregnancy, and expands the code set for OB/GYN specialists performing obstetrical ultrasounds and echocardiography in office settings. The most recent reissue on 11/26/2025 contains no substantive changes. Billing teams must ensure these provider types and specific CPT codes are configured in their systems to allow non-capitated reimbursement under the specified clinical circumstances.
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What to do
Action · 4 steps
01By 12/31/2025: Billing team must configure billing system to recognize Nurse Midwife and OB/GYN as eligible provider types for office-based obstetrical ultrasound reimbursement at non-capitated sites.
02Update claim validation rules to allow CPT codes S8055, 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76825, 76826, 76827, 76828, 76830, 76831, 76856, 76857, and 76999 when submitted by these provider types with appropriate diagnosis codes (ectopic pregnancy rule-out for Nurse Midwives; per Attachments A-D for OB/GYN).
03Verify that claims from these providers for these codes include required medical necessity documentation.
04Train billing staff that HMO/HMO-POS members do not require PCP referrals for OB/GYN ultrasounds.
If missed: Failure to implement these rules will result in claim denials or inappropriate capitation application.
Codes mentioned
S80557680176802768057681076811768127681376814768157681676817768257682676827768287683076831768567685776999
Original notice
00.03.10f, Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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