Ob-Gyn Coding Alert

  Question on CPT 76830 for Transvaginal Ultrasound from Codify's Ask an Expert Forum Question: We perform daily monitoring sonograms and report them using 76830. Should we include a written description of the service performed and the conclusion with the film? If yes, what specific details should we incorporate into the write-up, and would the insurer require this for each daily sonogram?
- New York Subscriber Answer: To report 76830 (Ultrasound, transvaginal), you must maintain a formal written report that documents the medical necessity for performing the ultrasound and the ultrasound findings (for example, tracking the ovarian follicle development).

According to the American College of Radiology and the American Institute of Ultrasound in Medicine, the ob-gyn’s documentation not only must be complete and detail the findings but should also detail the uterus, adnexa, cul de sac and cervix. If the physician simply monitors follicle development, some payers will recode your 76830 claim with... ...to read the full answer to this question or to post your own question, subscribe to Codify's Ob-Gyn Coder. You will get a 24X5 expert advice for all your difficult coding scenarios.
Take a FREE Trial to see the tool before you subscribe to it.   To get paid for both a transvaginal and pelvic ultrasound performed in the same session, proper documentation and correct modifier usage are crucial.

The Fort Collins Womens Clinic in Fort Collins, CO, routinely performs both the transvaginal and pelvic ultrasound during the same visit. Until recently, they were just filing for reimbursement for one of the procedures, using CPT code 76830 for the transvaginal procedure. In the last several months though they have been billing for two separate procedures using code 76830 for the transvaginal and 76856 for the pelvic ultrasound. More often than not payers have been paying for one service and denying the other. What is key in this scenario is charging and coding correctly while getting the maximum reimbursement.

The contention of the clinic is that both images are generally necessary to get a complete picture of the pelvic area. As Helene Stout of the Fort Collins Womens Clinic explains What you visualize with one imaging enhances what you see on another. We do the pelvic prior to the transvaginal in order to image the entire region. The challenge for Stout is that there is no CPT code that describes both procedures together.

The only ones weve had reimbursement at the outset are from commercial carriers says Stout. In every other case the claim for both has been initially denied and Stout has appealed every single decision. Her success rate [...]