Ob-Gyn Coding Alert

Question: We perform daily monitoring sonograms and report them using 76830. Should we include a written description of the service performed and the conclusion with the film? If yes, what specific details should we incorporate into the write-up, and would the insurer require this for each daily sonogram?

New York Subscriber Answer: To report 76830 (Ultrasound, transvaginal), you must maintain a formal written report that documents the medical necessity for performing the ultrasound and the ultrasound findings (for example, tracking the ovarian follicle development).

According to the American College of Radiology and the American Institute of Ultrasound in Medicine, the ob-gyn's documentation not only must be complete and detail the findings but should also detail the uterus, adnexa, cul de sac and cervix. If the physician simply monitors follicle development, some payers will recode your 76830 claim with 76857 (Ultrasound, pelvic [nonobstetrical], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]), even though the doctor performs the scan transvaginally rather than transabdominally.

Because the relative value units for the transvaginal code are higher than those for the limited scan - 2.57 for 76830 and 2.17 for 76857, meaning approximately $15 more for 76830 -- and because the carrier expects the ob-gyn to examine more for 76830, you should consider appending modifier -52 (Reduced services) to the transvaginal code. Without the modifier, you may be cited for coding a higher level of service than the physician documented if you are audited.