Ob-Gyn Coding Alert

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. She has 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. He performs a routine ultrasound and you report 76805. Because this is a screening for a malformation, your diagnosis code will most likely be Z36.3. In some cases, the physician may have documented “small for dates” in his scenario in which case the diagnosis code changes to O36.5920 (Maternal care for other known or suspected poor fetal growth, second trimester, not applicable or unspecified), but despite this diagnosis the initial ultrasound is still screening.

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]). In this case remember to include a diagnosis representing the type of twins (such as O30.032, Twin pregnancy, monochorionic/diamniotic, second trimester) as your secondary diagnosis.

Documentation requirements: According to Witt, when your ob-gyn performs 76805/+76810, he 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
• exam of maternal adnexa when visible.

Without these elements, you could be setting yourself up for an audit, not to mention being at risk for quality-of-care issues should something go wrong with the fetus at a later date.

Master Doc Requirements for More Complex U/S

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 the American Congress of Obstetricians and Gynecologists (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
• first-trimester exposure to drugs/chemicals.

Scenario: During a level I 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 specific malformations.

Additional documentation requirements: When your ob-gyn performs 76811/+76812, you have to 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.