Ob-Gyn Coding Alert

If you think that all of your practice's obstetric ultrasounds are "detailed," take note: CPT 2003 specifies which anatomic evaluation elements you must document when billing 76811 and 76812.

The new introduction to CPT's Obstetrical Ultrasound section advises you to report the new detailed ultrasound codes only if you evaluate all of the standard ultrasound elements, plus several additional anatomical components.

"Our standard ob ultrasound includes head and abdomen circumference measurements, femur length, amniotic fluid and placenta assessment, four-chamber heart and three-vessel cord evaluations, cardiac and limb movement evaluations, and cervix length measurement," says Carrie Caldewey, RCC, CPC, office manager at Redwood Regional Medical Group in Santa Rosa, Calif. "Adetailed examination would include all of those factors, plus ventricle examination, specific organ aspects, information regarding limb or spine formation, and other information. The detailed instructions in CPT are fairly clear on how the two differ."

Case #1: Detailed Ultrasound for History of Birth Defects

A 28-year-old patient presents for an initial obstetrical abdominal ultrasound at 18 weeks. Because her first child was born with cardiac birth defects, the ob-gyn performs a detailed ultrasound. The physician determines the patient is carrying twins, and examines the normal maternal and fetal structures, as well as cardiac outflow tracks, limb and spine formation and vascularization, and cerebral blood flow. The physician determines that both fetuses are healthy.

For this visit, you would report 76811 for the detailed ultrasound of the first fetus and 76812 for the detailed scan of the second fetus. You should link the detailed ultrasound codes to 651.03 (Twin pregnancy; antepartum condition or complication) and V23.49 (Pregnancy with other poor obstetric history).

Case #2: Ultrasounds Before and After Fetal Loss

A 26-year-old patient presents for a transvaginal ultrasound because of abdominal pain. The physician determines that the patient is six weeks pregnant with two fetuses in separate gestational sacs. The patient suffers from vaginal bleeding at week 15 and returns to the practice. A transabdominal ultrasound reveals that the patient lost one fetus. The practice performs a detailed anatomic examination of the remaining fetus, and the physician declares it healthy.

"For the initial visit, we would use American College of Radiology (ACR) guidelines (ACR's Ultrasound Coding User's Guide) to determine whether to use the standard transvaginal ultrasound code (76830) or an obstetrical transvaginal ultrasound code (76817)," Caldewey says. "The ACR dictates that a patient with an unconfirmed pregnancy even if pregnancy is later determined during the ultrasound warrants 76830. In this case, it sounds as though the patient was not aware that she was pregnant, so I would report 76830."

Note: Not all payers follow the ACR guidelines, so always request your carrier's regulations on when to use standard versus obstetrical ultrasound codes. In addition, ACR's stated rule of billing the gynecological transvaginal ultrasound code (76830) was written prior to the addition of the new obstetric transvaginal code (76817). This rule may change in the future to reflect current coding practices.

If the patient already knows that she is pregnant when she arrives for the ultrasound, report the new code 76817. Either way, report ICD-9 code 651.03 (Multiple gestation, twin pregnancy, antepartum condition or complication), 640.93 (Unspecified hemorrhage in early pregnancy, antepartum condition or complication), 641.93 (Unspecified antepartum hemorrhage, antepartum condition or complication) or a combination of these codes as the diagnosis, depending on the physician's direction.

"Even though the practice performed a detailed exam, it was still a follow-up to the original exam, so 76816 is still the correct code to assign," Caldewey says.

You can make an argument for reporting 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus) for the scan at 15 weeks because the physician has already documented twins and now there is vaginal bleeding. "The diagnosis code should be 651.33 (Twin pregnancy with fetal loss and retention of one fetus, antepartum condition or complication) for this visit," Caldewey recommends.

Case #3: Repeat Ultrasound to Confirm Fetal Health

A 32-year-old pregnant patient presents for her initial obstetrical transabdominal ultrasound. The technician dates the fetus at 13 weeks, five days. The ob-gyn is concerned that the fetus'head size does not match its other measurements, so he asks the patient to return at week 17 for a more detailed ultrasound. During the patient's second ultrasound, the physician measures the fetus'vital organs, tests the heart and movement rates, measures amniotic fluid, and examines the head size carefully. He determines that the fetus is healthy.

"I would code the initial ultrasound as 76801," Caldewey says. "The findings are a discrepancy in the head size versus other anatomical measurements (presumably the abdomen circumference and femur length), and I would therefore assign 653.83 (Disproportion of other origin, antepartum condition or complication) as the initial ultrasound diagnosis."

Even though the ob-gyn performed a detailed ultrasound, it was still a follow-up for the original finding of the abnormal head size. Therefore, you should report 76816 for the week-17 visit.

CPT Offers More Advice

CPT 2003 also offers new postdescriptor advice, guiding coders to the appropriate add-on codes and modifiers. For instance, previous CPTeditions instructed coders to use modifier -51 (Multiple procedures) for second and third fetal biophysical profiles (BPP, 76818-76819) with twins or triplets. This year, CPT recommends appending modifier -59 (Distinct procedural service) instead.

CPT revised existing codes to specify single gestations versus "each additional" gestation, fetal age and transvaginal versus transabdominal approach, notes Terry Tropin, RHIA, CPC, CCS-P, manager of coding education for the American College of Obstetricians and Gynecologists.

Use 76815 for 'Quick-Look' Ultrasounds

CPT advises coders to report 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) for "quick-look" exams "limited to the assessment of one or more of the elements listed in 76815."

In addition, you should note that CPT 2003 explicitly states that if the practice performs a transvaginal examination in addition to a transabdominal obstetrical ultrasound exam, you should report 76817 in addition to the transabdominal exam code (76856-76857). You likely will still have to append modifier -51 to the second scan, and payers may still deny the second charge.

The additional approach must have a written report of the findings just like the first approach. And the diagnosis must support medical justification for the second approach. Practices that routinely perform both approaches will likely not get both reimbursed because that becomes their standard of care when doing ultrasounds, as opposed to performing a second approach only when the ob-gyn cannot see what he or she needs to see because of the patient's anatomy or some other problem.

"The changes to the ultrasound codes are welcome, and the additional codes for multiple gestations will give us the ability to increase our reimbursement for the additional work," says Brenda Dombkowski, CPC, a coding specialist at Obstetric-Gynecology & Infertility Group in Cheshire, Conn. "But I hope insurance companies will follow CPT guidelines when making medical policy changes."