Ob-Gyn Coding Alert

Check out nonobstetric and all US procedure guidelines Beginning Jan. 1, if your ob-gyn evaluates fetal anemia using Doppler imaging, you'll be able to report 76820 - one of two new codes CPT added for fetal ultrasounds.
 
CPT 2005 also delivers specific ultrasound coding instructions in its new guidelines, such as how to choose between "complete" and "limited" codes and what exam elements CPT considers included in 76856. 1. How to Pick 'Complete' or 'Limited'
 
When coding for all ultrasound procedures, you must adhere to CPT 2005's guidelines. Check out these new features:

  All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated

  A final, written report should be issued for inclusion in the patient's medical record. 

  For those anatomic regions that have "complete" and  "limited" ultrasound codes, note the elements that comprise a "complete" exam. The report should contain a description of these elements or the reason that an element could not be visualized (such as, obscured by bowel gas, surgically absent, etc.).

  If the ob-gyn reports less than the required elements for a "complete" exam (that is, limited number of organs or limited portion of region evaluated), you should use the "limited" code for that anatomic region once per patient exam session.

  You should not report a "limited" exam of an anatomic region for the same exam session as a "complete" exam of that same region.

  You can separately report Doppler evaluation of vascular structures (other than color flow used only for anatomic structure identification). 

  Ultrasound guidance procedures also require permanently recorded images of the site to be localized, as well as a documented description of the localization process. The images and documented descriptions can exist either separately or together within the report of the guidance procedure.

  You should not separately report the use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report. 2. Learn the 76856-76857, 51798 Guidelines Don't be tempted to report 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) in addition to 76857 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]). You'll find that CPT includes 51798 in 76857, as specified in the guidelines for nonobstetrical procedures.
 
Learn what else may affect your ob-gyn practice:

Code 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) includes the ob-gyn's complete evaluation of the female pelvic anatomy. Elements of this examination include description and measurements of:

 uterus and adnexal structures
 measurement of the endometrium
 measurement of the bladder (when applicable)
 description of any pelvic pathology (such as, ovarian cysts, uterine leiomyomata, free pelvic fluid).
 
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