Question: In our reproductive endocrinology practice, we perform daily monitoring monograms and use 76830 to report the service. Is it required that a written description of the performed service and a conclusion accompany the film? If yes, what specific details need to be included in the write-up? Is this write-up required for each daily monogram that we bill?
New York Subscriber
Answer: It seems that you are referring to daily sonograms if you are billing 76830 (Ultrasound, transvaginal). In order to bill this code you must have a formal written report each time you bill it that states the medical necessity for doing the ultrasound and the findings of the ultrasound (e.g., tracking the development of the ovarian follicles, etc.). The guidelines from the American Institute of Ultrasound in Medicine and the American College of Radiology indicate that documentation must be complete and detail the findings. The guidelines also state that you need to document the uterus, adnexa, cul-de-sac and cervix.
If a practice is simply monitoring follicle development, some payers are recoding the claim to 76857
(Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]) even though the scan is performed transvaginally, rather than transabdominally.
The RVUs for the transvaginal ultrasound (76830) are higher than those for the limited scan (76857) because there is an expectation of a more extensive examination with the transvaginal ultrasound. For this reason, you may want to consider appending modifier -52 (Reduced services) to your 76830 claims. In the event of an audit, your use of 76830 for simple monitoring of follicle development could be cited for coding a higher level of service than your physician documented.
