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 [...]