Ob-Gyn Coding Alert

Question: The ob-gyn does an ultrasound and discovers a single intrauterine pregnancy in the vertex position with an estimated fetal weight of 4,281 grams, placing her in greater than the 90th percentile. Amniotic fluid index is normal at 13.8. There is a small anterior leiomyoma measuring 3.5 x 2.4 x 3.5 cm. There is no evidence of placental abruption. Excellent fetal movement is seen. The physician billed 76805, but I think the procedure is between 76805 and 76815. Who is right?

Kentucky Subscriber

Answer: To report 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), you must have documentation of all the elements CPT^® lists.

The information you provided does not list them. Specifically, you don’t mention a survey for fetal anatomy, which would include intracranial/spinal/abdominal anatomy and the four-chambered heart.

Translation: Under CPT^® rules, if the ob-gyn does not perform the complete procedure, you bill a limited procedure -- in this case, 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], 1 or more fetuses).