Ob-Gyn Coding Alert

Question: Two of our physicians routinely scan fetuses in the third trimester (32-36 weeks gestation) for evaluation of fetal size and position, amniotic fluid index, and placental grade. Should I report this as a limited (76815) or complete (76805) obstetrical sonogram?

Mississippi Subscriber

Answer: You should consider this a limited ultrasound (76815, Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) because 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) requires the ob-gyn to evaluate the maternal structures as well as the fetus. Consequently, you would need a diagnosis to justify reporting 76805. Remember that you can report 76815 even if the physician performs more than one of the examples listed in the code descriptor.

In addition, although a carrier may pay for 76805 the first few times you report it for the routine third-trimester scan, you would likely get audited for regularly performing this level of exam at the end of the pregnancy. And this could result in significant repayments to the insurance company.