Ob-Gyn Coding Alert

Question: A patient came in for a pregnancy confirmation. We reported a 99212 E/M visit, and the ob-gyn performed an ultrasound, which he does for all confirmations. Should I report 76805 for the ultrasound in addition to 99212? Also, which diagnosis codes should I use?

New York Subscriber

Answer: If the physician uses the ultrasound only to confirm pregnancy, you should not use 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). Instead, report the limited ultrasound code 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) or the transvaginal code 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal), if performed by this route.

Some practices do not charge for this ultrasound at all because it tends to be a quick check just to see if there is a heartbeat.

As for diagnosis coding, you have some options depending on the stated reason for the visit. You should not use V72.4 (Pregnancy examination or test, pregnancy unconfirmed), however, because you will know at the end of the visit whether the patient is pregnant. Code 626.8 (Other disorders of menstruation and other abnormal bleeding from female genital tract; other) is one possibility if the patient had missed a period or had a positive home pregnancy test with a missed period.

If you have already started the obstetric care at this visit, other possibilities include antenatal screening (V28.8, Other specified antenatal screening) or the code for uterine size-date discrepancy (646.83). If the ob-gyn is following intrauterine growth retardation, you should submit 656.53 (Poor fetal growth; antepartum condition or complication).

The answers for Reader Questions and You Be the Coder were provided by Melanie Witt, RN, CPC, MA, an ob-gyn coding expert based in Fredericksburg, Va.