Ob-Gyn Coding Alert

Although the ultrasonic guidance is a different procedure from the complete ultrasound, modifier -51 (Multiple procedures) is appended to the guidance code because it is a procedure of the same "type" and is viewed by the carrier as a multiple.

If the complete ultrasound is performed on a different day than the amniocentesis with ultrasonic guidance, modifier -51 would not be necessary because the two procedures are of different types. The only exception to this would be if the amniocentesis with ultrasound guidance is performed on the same service date, but at a different session. In that case, the ultrasound guidance code would need modifier -59 (Distinct procedural service) to clearly identify for the payer that this second procedure was performed at a different session or patient encounter than the initial complete ultrasound.

For physicians billing for ultrasound guidance, you should note that a report is required to document the procedure, which includes supervision and interpretation. If a complete ultrasound also is billed on the same date of service, that must be documented with a separate report as well.

Administering multiple ultrasounds, and the potential reductions in fees associated with them, is indicative of the need for practices to develop policies with their carriers to cover high-risk pregnancies. Once a pregnancy is diagnosed as high-risk, either because of the patient's age (e.g., V23.81, Elderly primigravida), pre-existing medical conditions (e.g., 648.03, Diabetes mellitus, antepartum condition or complication), multiple gestation (e.g., 651.03, Twin pregnancy, antepartum condition or complication) or other diagnosis, several additional tests, office visits and monitoring may be called for. Rather than get caught off guard by carrier rejections of claims "above and beyond" the normal range for global care, you should include a clause in your carrier contracts for high-risk ob care that specifies payment for additional services.

Wells also points out that denials are sometimes a problem for multiple ultrasounds when the patient has a history of complications with one or more previous pregnancies (e.g., 646.33, Habitual aborter, antepartum condition or complication) but is now having an uncomplicated pregnancy. "In those cases, the problem is not so much in coverage but in how the physician codes the diagnosis for the ultrasound. The history has to be indicated on the claim form, otherwise it looks like multiple ultrasounds for a noncomplicated pregnancy."

For nonpregnant patients, ultrasounds are ordered when a patient reports with a problem, or when an annual exam reveals a problem. Wells reports that the two most common reasons her practice orders non-ob ultrasounds are thickened endometrium and detection of the presence of fibroids. For instance, a 35-year-old patient reports to her gynecologist with a complaint of pelvic pain (625.9, Unspecified symptom associated with female genital organs) and bleeding between periods (626.6, Metror-rhagia). During the problem-oriented E/M visit (e.g., 99213, Office or other outpatient visit for the evaluation and management of an established patient ), the physical examination indicates the presence of a possible fibroid but is inconclusive. The physician schedules an ultrasound for the following week, when the ultrasound technician is in-office. The patient undergoes a transvaginal ultrasound (76830, Ultrasound, transvaginal) that reveals fibroid tumors (218.9, Leiomyoma of uterus, unspecified). Surgery is scheduled for a later date, and the tumors are removed.

Other codes for non-ob ultrasounds include 76831 (Hysterosonography, with or without color flow Doppler), 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76857 (... limited or follow-up [e.g., for follicles]).

Transvaginal ultrasound is increasingly the most common ultrasound method employed for detecting problems in the nonpregnant patient. The physician or ultrasound technician inserts a tube into the vagina to visualize the ovaries and other organs. This method is preferable to abdominal ultrasound, where the ultrasonic wand is passed over the abdomen. Because the sound waves have to travel through the abdomen to reach the reproductive organs, the visualization with abdominal ultrasound is not optimal. (In pregnant patients, most ultrasounds are performed transabdominally.) And because abdominal ultrasound requires a distended bladder but transvaginal ultrasound does not, many patients find the transvaginal approach more comfortable.

Hysterosonography is a relatively new procedure in which saline is injected into the uterus to distend the uterine cavity. The vaginal probe is inserted to look for polyps, fibroids or masses in the more fully visualized uterus. The saline forms an outline around the mass or lesion and allows for better visualization and measurement. When coding for a hysterosonograph, you also should submit the code for the injection of the saline, 58340* (Catheterization and introduction of saline or contrast material for hysterosonography or hysterosalpingography), if the same physician performs this procedure.