Ob-Gyn Coding Alert

Test your knowledge with a challenging two-part example.

Following up on the article presented in Ob-gyn Coding Alert (Volume 22, Issue 9) titled “Break Down the Mechanics of Obstetrical Ultrasound Coding,” get ready to dive back in to the intricate and nuanced world of obstetrical ultrasounds.

In this issue, the focus shifts beyond typical fetal and maternal care examinations to more detailed fetal anatomic examinations, quick looks, follow-up exams, and more.

Keep reading to check out the next installment of this handy obstetrical coding guide with examples and expert advice included.

Identify Extra Elements Needed to Report 76811

Sometimes, you’ll have to make the distinction between coding traditional second and third trimester fetal and maternal evaluation ultrasounds and their more detailed counterpart. Take a moment to consider how code 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) differs from that of 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). In addition to each of the elements needed to meet the requirements for 76805, the provider must also document the following:

• Detailed anatomic evaluation of the fetal/brain ventricles;
• Face, heart/outflow tracts, and chest anatomy;
• Abdominal organ specific anatomy; and
• Number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated.

It’s important to note that these examinations may come across under the same exam header. That’s why you’ve got to evaluate the dictation report closely in order to properly distinguish between 76805 and 76811. However, keep in mind that outside of any extenuating circumstances, the provider usually has no need to perform a more substantial evaluation than what’s included in 76805.

In fact, the Society for Maternal Fetal Medicine (SMFM) has stated that 76811 should never be performed as a routine scan; instead it should be performed by practitioners with special expertise in assessment, counseling or management of fetal anomalies. In order to qualify for 76811, the provider must document each element listed. If the provider does not document a given element, the dictation report should include a reason for non-visualization.

Know When to Report a Quick Look Exam

Next up, have a look at the limited obstetrical examination code 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses). Simply put, you’ll report this code when the provider does not document enough elements to reach the complete fetal and maternal evaluation codes. This exam is referred to as a “quick look” exam and includes one or more elements listed in the code description. “What you’ll typically find for 76815 is that the physician wants to ‘go back’ and look at something that was obscured or not seen the with the complete US,” says Kimberly M. Fifer, CPC, CEDC, manager of coding operations at Revenue Cycle Management in Roanoke, Virginia. However, code 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus) may be more appropriate to use.

The American College of Radiology (ACR) offers further guidance:

• “It is important to note that 76815 includes in its code description, ‘one or more fetuses,’ and should not be coded more than once per study, or per fetus. If a study is done to reassess fetal size, or to reevaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.”

As the ACR points out, it’s easy to improperly assign code 76815 when the documentation actually warrants code 76816. “You’ll typically see 76816 when the physicians ‘think’ there might be something wrong and opt to further pursue that particular issue,” Fifer says. The 76816 code can be a tricky one to fully untangle, but you should begin with a few important notes offered in the CPT^® manual:

“Code 76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound and should be coded once for each fetus requiring reevaluation using modifier 59 for each fetus after the first. If a study is done to reassess fetal size, or to re-evaluate any fetal organ-system abnormality noted on a previous ultrasound study, 76816 is appropriate.”

Hash the Point Home With This Example

Knowing when and where to report 76816 begins with an evaluation of the clinical indication. If the indication says follow-up, you must check patient’s chart history to determine the correct code. Keep in mind that the exam header may look identical to that of a complete fetal and maternal evaluation exam such as 76805. Have a look at this example to clear up any confusion:

Example: Patient admitted to ER for vaginal bleeding in pregnancy. A transvaginal obstetrical US is performed. The ob-gyn documents two subchorionic bleeds with a gestational age of 8 weeks and 3 days. One week later, the patient presents for a first trimester fetal and maternal US evaluation. The indication reads: “Evaluation of early pregnancy for dating. Follow-up of subchorionic hematomas.” One week following, the patient returns for a follow-up fetal and maternal US evaluation. The indication reads: “Follow-up of subchorionic hematomas.”

There are more than a few instances in this patient scenario that can cause problems for a coder. The first exam is relatively straightforward. The patient presents to the ER for a transvaginal obstetrical US. Given the circumstances of this exam, you should not consider any obstetrical US code outside of 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal). Code 76801, for instance, is a planned procedure that involves an extra set of criteria not included in 76817, but which also involves a transabdominal approach. Where this situation gets tricky is when you take a look at the planned evaluation one week following the ER encounter.

Assuming that this exam includes all the necessary criteria to report 76801, you should code it as such. However, there’s plenty of room to get tripped up when examining the indicating diagnosis. Obstetrical coders are often conditioned to see “follow-up” in the indication and immediately opt for code 76816. That’s why it’s always important to evaluate the patient’s entire obstetrical examination history before making any coding considerations.

In looking at the bigger picture, you’ll see that the “follow-up” is actually in reference to the original ER visit, not a prior fetal and maternal evaluation exam. As long as the exam meets all the required elements, you may report 76801. The last follow-up exam you’re tasked with coding is just that — a follow-up obstetrical examination. Providers will routinely order these exams for patients with documented subchorionic bleeding to make sure the hematoma has not progressed. As long as this exam meets the necessary CPT^® elements, you will report code 76816.