Ob-Gyn Coding Alert

An ob/gyn examining a high-risk ob patient or a patient whom he or she suspects to be high risk, may perform multiple procedures on a patient in one visit, including more than one ultrasound. Knowing the different ultrasound scenarios is the first step to clarifying and properly coding various ultrasound procedures.

For example, a physician suspects that an ob patient may have a fetal anomaly. The physician performs a complete sonogram (76805, echography, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation]). After the sonogram, the physician recommends an amniocentesis (59000, amniocentesis, any method). The patient agrees to the amniocentesis, and the physician performs an amniocentesis with sonogram guidance, all at the same visit.

Billing for Multiple Ultrasounds

Some ob/gyn practices have difficulty getting reimbursed for multiple ultrasounds in one day. This raises the question of whether billing for more than one ultrasound is correct in the first place.

Angela D. Wood, CCS, CPC, a senior healthcare consultant with Elliott, Davis and Company, L.L.P., an Augusta, Ga., CPA firm that offers healthcare consulting to its medical clients, asks, Will Medicare and other insurers allow me to bill for two complete ultrasounds during the same pregnancy? And can I bill for both a 76805 and a 76816 (fetal biophysical profile) that take place on the same day?

The question of how much is too much in ultrasounds is less important than how you document what was done. I think what matters more is not how many times you bill 76805 but what was actually done a complex or a limited scan, which would be code 76815 (echography, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position, or emergency in the delivery room]),says Patricia Horvatich, office manager for Robyn M. Cook, MD, a solo practitioner in Kealakekua, Hawaii,

Melanie Witt, RN, CPC, MA, former program manager for the American College of Obstetricians and Gynecologists (ACOG) department of coding and nomenclature and an independent coding educator, concurs with Horvatich. Witt also says that billing for both 76805 and the BPP (biophysical profile, 76818) at the same session is inappropriate. Unless you have a contract with your carrier that says you can bill more than one complete ultrasound in the pregnancy, then it is acceptable to do so. Practices should also bear in mind that with a complete ultrasound and a BPP on the same day, some payers are going to discount the second procedure.

Witt says that to justify the need for the second procedure, whether later in the pregnancy or at the time of the first ultrasound, there needs to be a separate report for each type of scan performed and billed. I have advised physicians that the documentation does not need to be arduous, but it should reflect the nature of the services performed and prove that each ultrasound was an integral part of the service through a written report.

Walking Through the Procedures

Before a physician can decide to perform an amniocentesis, a detailed obstetrical ultrasound of the fetus must be performed. This is accomplished by doing a complete obstetrical ultrasound (76805), which includes an assessment of viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, fetal weight estimation and basic anatomical review, Witt explains

Following the complete ultrasound, a physician may advise or the patient may request that an amniocentesis be performed. To safely perform an amniocentesis, ultrasonic guidance during the procedure is also necessary. This requires an additional ultrasonographer along with the physician performing the amniocentesis. This ultrasound guidance serves two purposes:

1. It allows the physician to safely guide the needle into the pocket of amniotic fluid while avoiding the fetus.

2. It provides continuous monitoring of the position of the needle in relation to the fetus while withdrawing the amniotic fluid.

When the complete ultrasound, the amniocentesis and ultrasound guidance are performed in the physicians office and the amniocentesis directly follows the complete ultrasound, it is appropriate to code for all three procedures as follows:

76805 (for the first ultrasound)
59000 (amniocentesis, any method)
76946-51 (ultrasonic guidance for amniocentesis, radiological supervision and interpretation; multiple procedures).

Witt explains that the -51 modifier is appropriate for the ultrasound guidance because it is a multiple procedure performed at the time of the amniocentesis. On the other hand, she says, the complete ultrasound does not require a modifier, because it is performed prior to the amniocentesis. She notes, however, that if a complete maternal and fetal evaluation is not performed, that is, if only the fetal evaluation is done, a modifier -52 (reduced services) should be added to 76805.

If the procedures are performed in a hospital where the ultrasonographer will be billing separately for the technical component, they would be coded as 76805-26 (professional component) and perhaps -52 (reduced services), 59000 and 76946-51-26. Modifier -26 is reported to denote that the physician is billing only for the professional component. This method of coding also assumes that the complete ultrasound immediately precedes the amniocentesis.

If the complete ultrasound is performed at a different time than the amniocentesis, or the amniocentesis is performed in a different location, you also have the option of using modifier -59 (distinct procedural service) on the ultrasound guidance code 76946. This modifier identifies a secondary procedure that is, among other things, performed at a different session or patient encounter or one that represents a different procedure or surgery.

For more help with insurance denials for multiple ultrasounds, ACOG developed a letter on ultrasound billing that can be obtained by contacting Terry Tropin, manager of coding education, at ttropin@acog.org.