Revision to Medicare Plus Blue payment policy for transvaginal and pelvic ultrasounds

Beginning April 1, 2021, for Medicare Plus Blue℠ members, we won’t pay for both a transvaginal ultrasound and a pelvic ultrasound if they’re both performed in the same session.

A transvaginal ultrasound (CPT code *76830) is a diagnostic test providing a look at the female reproductive organs. A pelvic ultrasound (CPT code *76856 or *76857) typically evaluates the same organs and represents a redundancy in services.

In extenuating circumstances, a provider may submit medical records on the clinical editing appeal form supporting the medical need for both procedures. Indications that may result in payment of both ultrasounds may include the inability to visualize all the structures or a finding of some pathology extending outside the pelvis. These should be clearly documented in the medical record and should be unique to the individual member.