Ob-Gyn Coding Alert

Question: Our ob-gyn practice is now certified to do nuchal translucency risk assessment. How should we report these services?

Oregon Subscriber

Answer: You should use 76813 (Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation). Add +76814 (... each additional gestation [List separately in addition to code for primary procedure]) when there is more than one fetus. These codes clearly define nuchal translucency scans.

Nuchal translucency ultrasound should include documentation of:

The sonographer who performs this measurement requires special training.

Check if your major payers have rules to ensure such training.

Also, if the scan is done as part of antenatal screening, you should link the ultrasound procedure to a diagnosis of V28.89 (Other specified antenatal screening).

ICD-10: When your diagnosis coding system changes, V28.89 will become Z36 (Encounter for antenatal screening of mother).