Ob-Gyn Coding Alert

Find out what indications and documentation you need for each type of procedure

If you-re confused about what prompts a routine ultrasound versus what prompts a more targeted one, help is here. Check your coding habits against these indications, get your documentation in order, and submit an ultrasound claim that will pass muster every time.
 
Did you know? As many as 70 percent of women in the United States undergo a routine ultrasound evaluation during their pregnancies, usually at 18-20 weeks- gestation. In fact, the American College of Obstetricians and Gynecologists (ACOG) maintains that one complete ultrasound should be included as a part of routine obstetric care.

Review Indications for Routine US

When a patient presents with suspected uterine or placenta abnormalities, you shouldn't automatically leap to the conclusion that the ob-gyn performed a complex ultrasound. These abnormalities are among the indications for a routine ultrasound.
 
Indications: When your ob-gyn performs an ultrasound on an ob patient in her second or third trimester, he may do this for one or several reasons. According to Melanie Witt, RN, CPC-OGS, MA, an independent coding consultant in Guadalupita, N.M., ultrasounds can estimate gestational age and fetal weight, determine fetal presentation, and provide the ob-gyn with evaluations of any number of the following aspects:
 - fetal growth
 - uterine size (date discrepancies)
 - fetal life
 - suspected uterine abnormality
 - abnormal alpha-fetoprotein (AFP)
 - suspected poly/oligohydramnios
 - suspected abnormalities of placenta
 - vaginal bleeding/amniotic fluid leakage
 - follow-up of suspected fetal anomalies
 - patients with history of prior congenital anomalies.

Notice: Code 76805 does not include a detailed fetal anatomic examination, says Cheryl Ortenzi, CPC, billing and compliance manager at BUOBGyn/Boston Medical Center in Boston. This separates a routine ultrasound from a detailed/targeted one.
 
Heads up: You should identify the reason for the scan using the appropriate ICD-9 code. If this ultrasound is a routine screening, you should use only V28.3 (Screening for malformation using ultrasonics). If the physician has reason to believe there is a problem with the fetus, use the 655 category code that identifies that reason. For instance, you might use 655.83 (Other known or suspected fetal abnormality, not elsewhere classified; antepartum condition or complication).
 
Scenario: A 35-year-old patient presents at 18 weeks gestation with decreased amniotic fluid. The ob-gyn suspects fetal renal anomalies and performs a routine ultrasound. You should report 76805 (Ultra-sound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> 14 weeks 0 days], transabdominal approach; single or first gestation).
 
However, if the same patient presents and is carrying twins at 18 weeks, your ob-gyn will perform a second ultrasound in addition to 76805 using add-on code +76810 ( ... each additional gestation [list separately in addition to code for primary procedure]).
 
Documentation requirements: According to Witt, when your ob-gyn performs 76805/76810, you must be certain that he documents:
 
 - number of fetuses and amniotic/chorionic sacs
 - measurements appropriate for gestational age
 - survey of intracranial/spinal/abdominal anatomy, four chambered heart, umbilical cord insertion site, and placenta location
 - assessment of amniotic fluid
 - exam of maternal adnexa when visible.

without these elements, you could be setting yourself up for a denial.

Master Doc Requirements for More Complex US

When a patient has a history of a genetic disorder that the ob-gyn can diagnose by ultrasound exam, you can substantiate the use of a more detailed/targeted ultrasound. Another way to look at it: -These codes are primarily for maternal fetal medicine (MFM) specialties,- says Kimberly Horn, CPC, an ob-gyn medical coder/insurance coordinator at Shanbour, Goff and Associates in Oklahoma City.
 
Indications: Other indications that will warrant the use of this more advanced ultrasound machine are:
 - suspected fetal anomaly during level I exam
 - severe intrauterine growth restriction (IUGR)
 - maternal diabetes
 - elevated AFP (serum or amniotic fluid)
 - oligo/polyhydramnios
 - two-vessel cord in level I exam
 - multiple pregnancy
 - fetal cardiac arrhythmia
 - first trimester exposure to drugs/chemicals.

Scenario: During a level I exam, the ob-gyn suspects a fetal anomaly and orders a detailed/targeted ultrasound. In this case, you would use 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation).
 
For each additional fetus, you should use +76812 (... each additional gestation [list separately in addition to code for primary procedure]). These ultrasounds allow the ob-gyn to take more detailed measurements and assess any malformations.
 
Rule of thumb: A routine ultrasound that is always done at 18-20 weeks is NOT 76811. You-ll report 76811 for a specific reason (such as suspected fetal anomaly) and should consider it a second-level ultrasound technicians perform on high-resolution special ultrasound equipment, says an ob-gyn coding expert based in Eau Claire, Wisc.
 
Additional documentation requirements: When your ob-gyn performs 76811/76812, you have to show that this detailed exam is medically indicated, Witt says. So in addition to the requirements for 76805/76810 listed above, your ob-gyn should also include the following elements:
 - fetal brain/ventricles
 - face
 - heart/outflow tracts
 - chest anatomy
 - abdominal organ specific anatomy
 - number/length architecture of limbs
 - evaluation of umbilical cord and placenta.