Ob-Gyn Coding Alert

Make sure you identify the reason for the scan using an ICD-10-CM code.

If you’re stuck deciding whether to report a routine or detailed ultrasound, then you need to zero in on your ob-gyn’s documentation. You should focus on two key elements: the equipment the ob-gyn used and the medical indications that prompted the procedure.

While many offices may be using ultrasound equipment that can perform a detailed ultrasound exam, medical need and physician expertise will determine if such a complex ultrasound, being interpreted by the physician with advanced expertise and training, is warranted. Experts say this will help you narrow down your selection.

Did you know? As many as 70 percent of women in the United States undergo a routine ultrasound (US) evaluation during their pregnancies, usually at 18-20 weeks’ gestation. In fact, the American College of Obstetricians and Gynecologists (ACOG) maintains that physicians should include one complete US as a part of routine obstetric care.

Impact: You must be certain you make the distinction between regular and detailed ob ultrasounds in your claims every time. If your practice undergoes an audit, incorrect coding may mean your payer could take reimbursement back.

Here Are the Indications for a Routine US

When a patient presents with suspected fetal or placental abnormalities, you shouldn’t automatically leap to the conclusion that the ob-gyn performed a complex US. These abnormalities are among the indications for a routine US.

Indications: When your ob-gyn performs a US on an ob patient in their second or third trimester, they may do this for one or several reasons. According to Melanie Witt, RN, 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
• Evaluating a history of prior congenital anomalies

Code a routine US based on the number of fetuses with 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; single or first gestation) and possibly +76810 (... each additional gestation [list separately in addition to code for primary procedure]).

You should identify the reason for the scan using the appropriate ICD-10 code. If this ultrasound is a routine screening, you should use only Z36.3 (Encounter for antenatal screening for malformations) or Z36.89 (Encounter for other specified antenatal screening). If the physician has reason to believe there is a problem with the fetus, use the O35 category code that identifies that reason. For instance, you might use O35.8XX1 (Maternal care for other (suspected) fetal abnormality and damage, fetus 1).

Test Yourself With This Scenario

Scenario: A 35-year-old patient presents at 18 weeks’ gestation and the fundal height has not progressed as expected, which leads to the physician to suspect decreased amniotic fluid. They have not had a previous ultrasound, and the physician wants to rule out any renal anomalies and get an accurate measurement of the amniotic fluid amount. They perform a routine ultrasound and you report 76805 because this is a screening for an anomaly.

If the same patient is carrying twins at 18 weeks, your ob-gyn will perform a second ultrasound in addition to 76805, reported with 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, they should document:

• 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; and
• Examination of maternal adnexa when visible.

Without these elements, you could be setting yourself up for an audit. Also, if something goes wrong with the baby and the ob-gyn does not include all this documentation, the ob-gyn could find themselves in serious trouble.

Here Are the 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 with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and possibly +76812 (... each additional gestation [list separately in addition to code for primary procedure]). According to ACOG, detailed examinations are best performed by an ultrasonographer with advanced training and interpreted by a maternal fetal specialist.

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, and
• First-trimester exposure to drugs/chemicals.

Scenario: During a level 1 exam, the ob-gyn suspects that the patient has a fetal anomaly and orders a detailed/targeted ultrasound. In this case, you would use 76811.

For each additional fetus, you should use +76812. These ultrasounds allow the ob-gyn to take more detailed measurements and assess any malformations.

Additional documentation requirements: When your ob-gyn performs 76811/+76812, you must show that this detailed exam is medically indicated, Witt says. Documentation must also be more detailed, 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

Focus on 2 Differences

Here’s how you should separate detailed from routine ultrasounds.

The routine ultrasound code 76805 does not include a detailed fetal anatomic examination, experts say. This separates a routine ultrasound from a detailed/targeted one.

Also, keep in mind that 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 that technicians with advanced training perform on high-resolution special ultrasound equipment.