Ob-Gyn Coding Alert

The latest in ultrasound technology 3-D ultrasound is being used to further augment what is seen in the 2-D ultrasound, and while the cutting-edge procedure can be a godsend for patients, it can cause major headaches for coders.

With 2-D (76805, Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation]), a physician can move the mother and fetus around to see the limb or ear, but there is no way to determine the structures immediately around it.

Manipulation of the images allows for a bigger picture with a 3-D ultrasound. According to Shelia D. Harris, RT, RDMS, manager for ultrasound services, maternal-fetal medicine/genetics at St. and children, Evansville, Ind., "The appropriate code to report for this procedure is 76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computerized axial tomography, magnetic resonance imaging, or other tomographic modality)." The coding committee at ACOG agrees with Harris and is recommending this code as well.

Philip N. Eskew Jr., MD, medical director for Women and Infants, Family Life Center, St. Vincent Hospital in Indianapolis, says, "The 3-D is very helpful in recognizing gynecological tumors, sonohysterograms, and facial abnormalities such as a cleft lip. Also, if there is a spine defect seen in the 2-D, the 3-D will allow the physician to pinpoint the exact vertebra involved."

Practices that use the 3-D ultrasound say it is not a replacement for the 2-D, but a supplement. Most patients undergo a 2-D first because interpreting the 3-D image is time-consuming and the equipment is expensive. If there is no reason to believe there is a problem with the fetus, then the time and cost of performing the 3-D ultrasound are not justified.

Remember that because 3-D ultrasounds are relatively new procedures, experts say you should demonstrate that the 2-D ultrasound was performed first.

"Usually insurance does not cover the image, unless it's a medical necessity," Harris says.

"A2-D ultrasound should be performed first, then, if medically necessary, a 3-D scan. Most likely, if you charge for both, documentation of both studies would need to be sent with the insurance claim," she says. Medical necessity indicates an abnormality that cannot be fully evaluated with 2-D, but additional information can be acquired through the use of 3-D such as locating an ectopic pregnancy (633.x) only if it is a confirmed finding. "If the physician is simply looking for a problem," saysMelanie Witt, RN, CPC, MA, an ob/gyn coding expert based in Fredericksburg, Va., "you should code the symptoms or use the antenatal screening code V28.8."

Joshua Copel, MD, director of obstetrics at Yale/New Haven Hospital, has been successful in receiving reimbursement for 3-D when the reason for the procedure was a fetus with a hand abnormality.

In that situation, the ICD-9 code would come from the 655.xx category, Witt says. "There is no specific code for hand abnormality unless you use the chromosomal code (655.1x) or 655.8x (Other known or suspected fetal abnormality, not elsewhere classified)."

Note: You cannot use the code for the abnormality that is listed in the perinatal chapter of ICD-9 because these can only be used on the pediatric record after birth.

Other justifiable reasons for 3-D ultrasounds may be on the horizon. "It is my opinion that initially face and limb anomalies will be the major areas of reimbursement, but you should check with your individual carrier," Copel says.

For example, "CareFirst, BlueCrossBlueShield will reimburse for 3-D ultrasounds if they are medically necessary," says Michelle Defoe, communications representative for the company. "However, payment is also based on a Aetna U.S Healthcare will also reimburse for 3-D but only after a medical supporting documentation is very important because each case is examined individually.

"Modifiers may be required in some situations," Harris says. For example, if a physician performs a 2-D ultrasound in a hospital and uses the interpretation of the scan may be billed. Therefore, you should code 76805-26 (Professional component).

Additionally, "if two different ultrasounds are performed on the same day, the most expensive procedure should be listed on the claim first, with the second procedure appended with modifier -51 (Multiple procedures). So, for example, in a case where a complete ultrasound (2-D) is performed and then a 3-D is done, report 76805 and 76375-51," Harris says.

Eskew agrees and says that you should send a letter with your claim explaining the necessity and usefulness of the 3-D to obtain the most information as possible. "This is a very valuable adjunct to the 2-D and will in time become quite common," he adds.