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:

1. the fetal crown-rump length

2. verification of the sagittal view of the fetal spine

3. three measurements of the maximum thickness of the subcutaneous translucency between the skin and the soft tissue overlying the cervical spine

4. image documentation and a final written report.

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).

-- The answers for Reader Questions and You Be the Coder provided by Melanie Witt, RN, CPC, COBGC, MA, an ob-gyn coding expert based in Guadalupita, N.M.