Ob-Gyn Coding Alert

Here’s the documentation you must have for each type of procedure

If you’re wondering whether to code routine and more targeted ultrasounds, here’s the keys — the equipment your ob-gyn uses and the medical indications that prompted the procedure. 

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

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.

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 US. These abnormalities are among the indications for a routine US. 

Indications: When your ob-gyn performs a US on an ob patient in her second or third trimester, he may do this for one or several reasons. According to Melanie Witt, RN, COBGC, MA, an ob-gyn coding expert based 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 death
• 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.

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-9 code. If this ultrasound is a routine screening, you should use only V28.3 (Encounter for routine 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).

Test Yourself With This Scenario

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.

If the same patient presents and 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, 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. Also, if something goes wrong with the baby and the ob-gyn does not include all this documentation, the ob-gyn could find himself in serious trouble.

Master Doc 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]). “These codes are primarily for maternal fetal medicine (MFM) specialties,” says Kimberly Horn, CPC, BSHA, owner and operator of Village Coding in Village, Okla. 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 malformations.

Additional documentation requirements: When your ob-gyn performs 76811/76812, you have to show that this detailed exam is medically indicated, Witt says. 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. But a detailed exam must be supported by medical need so just because the ob-gyn can perform a detailed exam, does not mean it is clinically indicated.

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 perform on high-resolution special ultrasound equipment.