Ob-Gyn Coding Alert

Pay attention to this 'separate report' advice.

If you're providing more than one ultrasound per obstetric patient - even during the same visit - make sure you're coding for them. Otherwise, you could be undercutting your practice's bottom line.

As much as 70 percent of women in the United States undergo a routine ultrasound evaluation during their pregnancies, usually at 18-20 weeks' gestation. In fact, the American Congress of Obstetricians and Gynecologists (ACOG) maintains that one complete ultrasound should be included as a part of routine obstetric care.

Keep Ultrasounds Out of the Global

Although many insurance providers include ultrasound as a standard part of the ob global package (for example, 59400,Routine obstetric care including antepartum care, vaginal delivery [with or with episiotomy, and/or forceps] and postpartum care), CPT® maintains otherwise. "Antepartum care includes the initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, and monthly visits up to 28 weeks gestation, biweekly visits to 36 weeks gestation, and weekly visits until delivery," CPT® states. "Any other visits or services within this time period should be coded separately."

In addition, the AMA has stated that the ob global package does not include diagnostic ultrasound, according to the CPT® Assistant.

Code Those Ob Ultrasounds

Generally, physicians use obstetric ultrasounds (for example, 76801, Ultrasound, pregnant uterus, real time with imagedocumentation, fetal and maternal evaluation, first trimester [<14 weeks 0 days], transabdominal approach; single or first gestation) to show viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, and fetal weight estimation and allow basic anatomical review.

Doctors often use these ultrasounds as more precise dating tools to better determine delivery dates. Or the ob-gyn can use them to check viability when the patient has a threatened miscarriage or has a history of habitual miscarriages.

For a more detailed fetal view using ultrasound, you would report 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) or +76812 (... each additional gestation [list separately in addition to code for primary procedure]). These ultrasounds allow the ob-gyn specialist to take more detailed measurements and assess any malformations.

Multiple Ultrasounds Mean Multiple Codes

Apart from 76801 and 76805 (... after first trimester [> or = 14 weeks 0 days] ...), you generally will use the other pregnancyrelated ultrasounds (76811-76828) for high-risk or problem pregnancies. If a patient presents with problems that indicate she may be high-risk or if a routine ultrasound indicates a problem that may need to be followed, the ob-gyn may decide to schedule more than one ultrasound during the pregnancy, perform one or more amniocenteses, or even do multiple ultrasonic procedures during the same visit.

For example, a 35-year-old patient presents at 18 weeks of gestation for a routine ultrasound (76805), but the ultrasound indicates a possible fetal anomaly. Consequently, the ob-gyn decides to perform an amniocentesis (59000, Amniocentesis; diagnostic) with ultrasonic guidance (76946, Ultrasonic guidance for amniocentesis, imaging supervision and interpretation) during the same visit. The physician uses the ultrasound to visualize needle placement as he extracts the amniotic fluid sample from the pregnant uterus while avoiding needle contact with the fetus.

When the ob-gyn performs the regular ultrasound, amniocentesis and ultrasonic guidance in his office and the amniocentesis directly follows the ultrasound, you should code this as:

• 76805
• 59000
• 76946-51.

Even though the ultrasonic guidance is a different procedure from the regular ultrasound, you should append modifier 51 (Multiple procedures) to 76946 because it is the same "type" of procedure and many carriers consider it a multiple. If the doctor performs the regular ultrasound on a different day than the amniocentesis with ultrasonic guidance, then you would not need to use modifier 51 because the two procedures are of different types.

Remember, however, that if you're reporting ultrasonic guidance, the ob-gyn should include a report in the medical record documenting the procedure and what the physician sees via the guidance because like all ultrasound procedure, guidance includes supervision and interpretation. If the physician also performs a regular ultrasound on the same date of service, that requires its own separate report.

High-Risk Pregnancies Require Multiple Ultrasounds

High-risk pregnancies frequently require multiple ultrasounds to assess the fetus's development. The high-risk status may be caused by the patient's age, pre-existing medical condition(s), multiple gestation, or other diagnoses. To avoid carrier rejections for claims that are above and beyond the normal range for global ob care, you should include a clause in your carrier contracts for high-risk ob-care that specifies payment for additional services. In addition, denials may be a problem for multiple ultrasounds when the patient has a history of complications with previouspregnancies (for example, 646.33, Recurrent pregnancy loss; antepartum condition or complication) but is now having an uncomplicated pregnancy. To avoid this problem, be sure to include the patient's history on the claim form. Otherwise, such cases will look like multiple ultrasounds for a noncomplicated pregnancy. For instance, you would assign V23.49 (Pregnancy with other poor obstetric history) for supervision of a high risk pregnancy due to recurrent fetal loss in a previous pregnancy.

ICD-10: In 2013, ICD-9 code 646.33 expands into three options, based on the patient's trimester:

• O26.21, Pregnancy care for patient with recurrent pregnancy loss, first trimester
• O26.22, ... second trimester
• O26.23, ... third trimester.

Code V23.49 becomes:

• O09.291, Supervision of pregnancy with other poor reproductive or obstetric history, first trimester
• O09.292, ... second trimester
• O09.293, ... third trimester.