I suppose the time has come to let the cat out of the bag. The Max Out of Pocket crew is expecting! We are really excited! But more on that later. First things first, how much does an obstetric ultrasound cost in the first trimester?
Let’s be real. I am probably the last person the healthcare finance industry wants going through this process. As healthcare pricing and surprise medical bills have become a hot topic in recent years, more and more expecting parents are asking questions about how much things are going to cost them.
They should. Some of the wild pricing swings I have witnessed throughout my career in healthcare finance are almost unexplainable. But you need to know what questions to ask.
One of the early expenses during the pregnancy process will be an ultrasound. This is often initially done during the first trimester to both confirm the pregnancy and estimate how far along the mother is. The first trimester is generally considered the period of time when the mother is less than 14 weeks pregnant.
But how much does an obstetric ultrasound cost in the first trimester?
Great. Is Max going to take one of the hallmark moments of pregnancy and financially dissect it? Absolutely. But now, I have good reason to.
Two Approaches to the Ultrasound Exam
The first thing to know is there are two approaches to the obestetric ultrasound exam: the transabdominal approach and the transvaginal approach.
The transabdominal approach is typical of what you might see on a TV commercial or in the movies.
Another approach is transvaginal. My understanding is the transvaginal approach is mostly used early in the pregnancy when transabdominal ultrasound did not provide enough information.
In my experience, depending on the clinic, I sometimes see these both ordered together right from the start. Physician preference or protocol might have something to do with how these are ordered, but I am not an expert on ordering patterns. So as always, talk through this with your provider if you have questions about the appropriate approach.
Today, I will be covering the traditional transabdominal approach during the first trimester where a transducer is moved over the abdomen. The mother is asked to present with a full bladder to help get clearer images. The transducer produces ultrasonic waves directed at the fetus, pregnant uterus, and surrounding pelvic structures of the mother.
And just like that, hopefully, you have an image of a fetus. Here is ours from back in September.
Obstetric Ultrasound CPT Code
In healthcare, we represent almost every little service with a five digit code.
The CPT code that represents this first ultrasound is 76801. It is an abdominal ultrasound of a uterus that has been pregnant for less than 14 weeks. There is both a fetal and maternal evaluation done during this service. The radiologist reviews the images of the fetus, pregnant uterus, and maternal pelvic structures and provides a written interpretation of the images back to the OBGYN and midwife.
The “consumer-friendly” description of this service is “an abdominal ultrasound of a pregnant uterus“.
If the mother happens to have a second routine ultrasound done in the first trimester, 76801 is used as well. As you might expect, she will be charged again for the service.
I should mention, a separate ultrasound where they measure some fluid near the fetal neck is also often ordered at some point, but we will learn more about that in another post.
Facility Fee vs. Professional Fee
There are often two separate fees for an ultrasound. This is one of the harder concepts for patients to understand.
The facility fee represents the equipment, supplies, and trained technician performing the actual ultrasound. You might also hear this called the “technical” component of the service. Unlike what you might have seen on daytime television or Dr. House, the obstetrician or midwife normally wouldn’t do the official ultrasound where measurements are taken. It is often farmed out to a trained sonographer.
Then there is the professional fee. This fee is for a trained radiologist to write a written report of his or her interpretation of the image. The radiologist should not be confused with the sonographer as these are two separate skill sets. This is sometimes called a “read fee” for “reading” the image. Again, generally, the obstetrician or midwife wouldn’t necessarily do the formal interpretation of the image.
If the service is provided in a clinic or imaging center, both the facility fee and radiologist interpretation are often combined into one charge. This is sometimes referred to as a global charge.
However, if the service is provided in a hospital imaging department, the radiologist interpretation will often be a completely separate charge/claim from the hospital facility fee.
How Much does an Obstetric Ultrasound Cost in the Hospital?
Sometimes, the OBGYN office will be conveniently located on a hospital campus not too far from the imaging department. A short walk down the hall will take you out of the clinic setting and into the hospital setting. It might even be right across the street.
In my experience, unless it is an emergency, this convenient walk will cost you. The second you walk into that hospital you are subject to the inflated prices that come along with it.
I have personally seen hospital pricing for this ultrasound range anywhere from $250 – $1,200. The hospital I would likely have this service charges about $925. But let’s hope Max never needs to report to imaging to have an obstetrical ultrasound.
Of course, that is the retail price. I would get mine on sale with a discount through my insurance. My insurance negotiates that $900 hospital price down to $475. That entire $475 balance would hit my deductible and come right out of my pocket.
So, I am already out-of-pocket $475, and the radiologist has not even read my image yet. I would get a separate bill for that. I believe my insurance would get the “read” fee down to about $70, all of which would hit my deductible.
$475 facility fee + $70 read fee = $545 out-of-pocket
I wonder how many ultrasound images a radiologist can read per hour? Could make for some good cash flow.
A Few Examples
I thought sharing a few examples of hospital pricing might be helpful.
You might remember, I defended Hudson Hospital in Wisconsin last year against NPR on a little billing mishap they had with nitrous oxide. I called that one Midwife Crisis, $5,000 nitrous. The midwife was clearly trying to stir the pot.
Since we happen to be talking about the pregnancy process again, I was wondering what Hudson Hospital charges for the abdominal ultrasound. According to their chargemaster, they charge $502. Their price comes in about $400 less than the local hospital I would go to.
The University of Michigan charges a little more.
Johnson Memorial in Indiana charges $679. I love their chargemaster because they went above and beyond by including the CPT code.
How much does an Obstetric Ultrasound Cost in a Clinic/Imaging Center?
If you receive this service in an actual clinic or imaging center, we would be looking at a much more reasonable price of $150 – $325 for the entire service. The 50th percentile would come in at around $220. If you have insurance, it would likely negotiate that price down even further.
My own insurance has negotiated this down to about $170 for everything at a clinic in my market. That includes the procedure itself and the professional interpretation.
For us, that’s $375 cheaper than having it in the hospital.
So, unless you have already hit your max out-of-pocket for the year, I would try to have the ultrasound in a clinic setting. It might even make sense to drive to an imaging center if your clinic/OBGYN does not offer an ultrasound within the clinic walls.
How much does the Government Pay?
I always like to compare what government payers like Medicare might pay for the same service. They have the ultimate pricing power and are a good indicator of what it actually costs to provide a service. State Medicaid programs often pay less than cost.
How much does an obstetric ultrasound cost the Medicare program? Although not a lot of Medicare patients are having babies, they will pay about $118 for the entire service in the clinic setting in 2021. That covers both the ultrasound ($73) and professional interpretation ($45). That rate would be adjusted slightly depending on where in the country the service is provided.
If the service was provided in a hospital, Medicare would pay the hospital $109 in 2021. Another $45 or so would be paid for the professional interpretation. That’s about $154 out the door.
North Carolina Medicaid would pay a clinic $107.22 for the full global charge according to their most recent fee schedule from 12/21/2020. It is not uncommon for the state Medicaid programs to come in under Medicare rates like this.
As you can see, the pricing differences for a relatively simple service can be stark. If you are lucky enough to have insurance, you have even more work to do because you need to find out how much they have negotiated the price down to. That goes for both the clinic and hospital setting.
My recommendation for most consumers would be to have the ultrasound done at a clinic or imaging center, assuming it’s not an emergency. It would save the Max Out of Pocket crew about $375 to drive to an imaging center for this service.
That said, if you know you are going to meet your max out-of-pocket for the year, pricing starts to go out the window. If you are due late in the year, odds are you will hit your max out-of-pocket and your insurance will start picking up all the bills. That makes all this a moot point and convenience might come more into play.
But it is worth keeping an eye on things, particularly if your services are going to be split up over two calendar years. These early tests can really add up as they all hit your deductible. Then, the deductible will re-set again for you in January. Keeping pricing in check and going to a clinic or imaging center might save you some serious money.
Homework: How much does an obstetric ultrasound cost at your local hospital?