Ob-Gyn Coding Alert

If an obstetric patient undergoes multiple ultrasounds, even during a single visit, and you're not reporting these services separately from the global ob package, you could be seriously undercutting your practice's bottom line.

Check this out: In the United States, almost 70 percent of pregnant women undergo a routine ultrasound evaluation, 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. Patients and pregnancies can vary. "You can have a normal pregnancy where the ob-gyn performs only the anatomical survey and that's all -- but then you could have another pregnant patient who requires serial ultrasounds to access growth," says Donna C. Kroening, CPC, COBGC, reimbursement manager for the Department of Obstetrics and Gynecology at the Medical College of Wisconsin in Milwaukee.

Generally, physicians use obstetric ultrasounds (for example, 76801, Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [<14 weeks 0 days], transabdominal approach; single or first gestation) to show viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, and fetal weight estimation and to allow a basic anatomical review.

For regular types of ultrasounds, you'll use 76801-76802 for less than 14 weeks gestation and apply routine screening code V28.3 (Encounter for screening for malformation using ultrasonics). Use 76805-76810 for greater than 14 weeks gestation and apply V28.3, says Peggy Stilley, CPC, CPC-I, COBGC, ACS-OB, clinic manager for the University of Oklahoma in Tulsa.

Doctors often use these ultrasounds as more precise dating tools to better determine delivery dates. Or the ob-gyn can use them to check viability when the patient has a threatened miscarriage or has a history of habitual miscarriages.

For a more detailed fetal view using ultrasound, you would report 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation). This code has 3.33 work relative value units (RVUs), meaning if you mistakenly counted this ultrasound as part of the global ob package, your practice would lose about $120. These ultrasounds allow the obgyn to take more detailed measurements and assess any malformations.

Important: You should reserve this level of ultrasound for cases where the ob-gyn suspects fetal  anomalies either due to a finding on a previous ultrasound or due to family or personal history concerns. In other words, you'll use 76811-76812 when the ob-gyn does "complete anatomy exams" due to "abnormal results from a previous exam, an abnormal lab result, or some other abnormal finding," Stilley says.

Apart from 76801 and 76805 (... after first trimester [> or = 14 weeks 0 days] ...), you generally will use the other pregnancy-related ultrasounds (76810-76828) for high-risk or problem pregnancies. If a patient presents with problems that indicate she may be high-risk or if a routine ultrasound indicates a problem that may need to be followed, the ob-gyn may decide to schedule more than one ultrasound during the pregnancy, perform one or more amniocenteses, or even do multiple ultrasonic procedures during the same visit.

Example: A 35-year-old patient presents at 18 weeks of gestation for a routine ultrasound (76805), but the ultrasound indicates a possible fetal anomaly. Consequently, the ob-gyn decides to perform an amniocentesis (59000, Amniocentesis; diagnostic) with ultrasonic guidance (76946, Ultrasonic guidance for amniocentesis, imaging supervision and interpretation) during the same visit. The physician uses the ultrasound to visualize needle placement as he extracts the amniotic fluid sample from the pregnant uterus while avoiding needle contact with the fetus.

When the ob-gyn performs the regular ultrasound, amniocentesis, and ultrasonic guidance in his office and the amniocentesis directly follows the ultrasound, you should code this as:

• 76805

• 59000

• 76946-51.

"If your ob-gyn found an anomaly and documented the additional elements, you could bill 76811 as well," Stilley points out.

Even though the ultrasonic guidance is a different procedure from the regular ultrasound, you should append modifier 51 (Multiple procedures) to 76946 because it is the same "type" of procedure and many carriers  consider it a multiple. If the doctor performs the regular ultrasound on a different day than the amniocentesis with ultrasonic guidance, then you would not need to use modifier 51 because the two procedures are of different types.

Remember, however, that if you're reporting ultrasonic guidance, the ob-gyn should include a report in the medical record documenting the procedure, which includes supervision and interpretation. If the physician also performs a regular ultrasound on the same date of service, that requires its own separate report. "Ask, 'why are you doing multiple ultrasounds?'" Kroening says. You need to "justify the medical necessity with the diagnosis" and correct documentation.

High-risk pregnancies frequently require multiple ultrasounds to assess the fetus's development. The high-risk status may be caused by the patient's age, pre-existing medical condition(s), multiple gestation, or other diagnoses.

To avoid carrier rejections for claims that are above and beyond the normal range for global ob care, you should include a clause in your carrier contracts for high-risk ob care that specifies payment for additional services.

In addition, denials may be a problem for multiple ultrasounds when the patient has a history of complications with previous pregnancies (for example, 646.33, Habitual aborter; antepartum condition or complication)but is now having an uncomplicated pregnancy. To avoid this problem, be sure to include the patient's history on the claim form by also reporting a V23 high-risk code in most cases. Otherwise, such cases will look like multiple ultrasounds for a noncomplicated pregnancy.

What it comes down to is documentation, documentation, documentation, experts say.