Ob-Gyn Coding Alert

Ultrasound screening is increasingly a more common practice in obstetrical care. According to a recent technical bulletin from the American College of Obstetricians and Gynecologists (ACOG), 70 percent of all pregnancies in the United States undergo routine ultrasound evaluation even though the clinical benefits of routine evaluation have not been established. Nevertheless, it remains a growing part of the obstetric care because it helps reduce the incidence of labor induction in pregnancies that have gone past their suspected post-due date, and helps decrease the frequency of undiagnosed major fetal anomalies and undiagnosed twins. In addition, ob patients are beginning to expect ultrasound as part of their routine obstetric care.

How many ultrasounds are allowed to be performed per pregnancy, and which specific codes should be used? asks Sandra Flores, certified coding specialist in the ob/gyn department at Texas Technical School of Medicine in El Paso, TX. Both of these questions are commonly heard from subscribers to OCA.

Part of Global?

Many patients and some insurance companies expect ultrasound to be included in global ob billing. Its definitely not part of global, says Lisa A. Lorence, coding specialist for Toledo Clinic, Ob/Gyn, in Toledo, OH. Lorences view is consistent with CPT definitions and a clarification by the AMA published in the April 1997, CPT Assistant, that there is no inclusion of diagnostic ultrasound in the global ob package. Ultrasounds are a separate procedure and should be reported as such. This does not mean that all insurance payers will see it this way, but when it comes to correct reporting, ultrasounds are not part of routine ob global care.

The CPT OB Ultrasound Codes

So, if correct reporting requires separate codes, which codes should you use? The common CPT codes are found in the Radiology Diagnostic Ultrasound section of the CPT, but the descriptions of these codes are vague, says Walter C. Blackham, chairman of the Radiology Business Management Associations (RBMA) coding committee. Coders will always have trouble with these codes, he explains. There is no real good explanation for [how to use] them. Melanie Witt, RN, CPC, MA, program manager for ACOGs department of coding and nomenclature agrees. There are no good definitions for the ultrasound codes as they appear in the CPT, she says. ACOG and the American Institute of Ultrasound in Medicine (AIUM) are working to remedy this situation. For now, the following descriptions of the most common codes and problems will assist the coder in choosing the right codes.

The Complete, Limited and Follow-up Ultrasounds

According to a January 1998 ACOG opinion paper, A complete ultrasound (echography) of the pregnant uterus, which involves a complete fetal and maternal evaluation, is for the most part, an anatomic evaluation. For the maternal evaluation, the physician is looking at the size and position of the uterus, placental and cord location and whether there are any uterine or other anomalies that might impact the pregnancy. For the fetal evaluation, the head is measured, and the neck, abdomen, chest, limbs and organs of the fetus are examined. Signs of fetal life, such as heart rate, breathing and fetal activity are also noted. The complete ultrasound is reported once using codes 76805 for a single gestation and 76810 for multiple gestations after the first trimester. These codes will normally only be used once during the pregnancy. A follow-up to or repeat of a previous ultrasound will be coded as 76816, while a quickie fetal check is usually coded as a limited ultrasound (76815).

In practice, OCA found several coders who say that they have been successfully billing for repeat ultrasounds using the 76805 instead of the 76816, providing that the ultrasounds were linked to clear medical necessity.

ACOGs opinion paper states some of the common reasons for performing a complete ultrasound exam on the pregnant uterus are: to establish the date of the pregnancy, to check for the presence of a previous malformation or anomalies, to investigate a disparity between calculated age of the fetus and size, to confirm or rule out the possible presence of twins, and to evaluate bleeding. Witt points out that establishing medical necessity is often the pivotal point in successful reimbursement. Many physicians simply write dates or LMP as a reason for doing an ultrasound, she says. This would be coded as V28.8 (other specified antenatal screening), but it does not justify the complete ultrasound. Unless the physician did a complete maternal and fetal evaluation, the only choice will be a limited (76815) ultrasound in this case. Some physicians do an ultrasound at a set number of weeks on all ob patients regardless of medical necessity. These ultrasounds will generally be viewed as part of the global package.

According to the CPT, the limited ultrasound (76815) is used to establish fetal size, heart beat, placental location, fetal position, or, in an emergency situation, to assist the physician in the delivery room.

Tip: The limited ultrasound (76815) is for any situation in which less than a complete ultrasound is performed. The limited code is not only for an emergency situation.

Fetal Biophysical Profile (BPP)

In last months issue of OCA, the BPP was covered in depth, but, according to Blackham, denials of the BPP are a common ob ultrasound problem. He states that in a 1997 request from the RBMA to the AMA for clarification, the AMA made the following reply. If the fetal biophysical profile (76818) is performed in conjunction with any of the pregnant uterus echographic procedures (76805-76816), then it would be appropriate to report each service with individual codes to identify the total number of services provided. The fetal biophysicial profile identifies elements different from the pregnant-uterus echography procedures. Due to this, if the biophysical profile and any of the aforementioned procedures were performed during the same session, then it would be appropriate to report the services with separate codes. But Blackham also adds that correct reporting and reimbursement are two different matters, and that payers are likely to reimburse for only one procedure.

Transvaginal Ultrasound

Increasingly, when a complete pregnant pelvic ultrasound is performed, providers are performing a transvaginal ultrasound (76830). The complete ultrasound is performed on the abdomen and the transvaginal uses a probe in the vagina. According to Blackham, this has also become a common denial. When the RBMA questioned the AMA about it, the AMA responded: From a CPT coding perspective, if a transvaginal echography is performed in the same session or date as a pelvic echography, then it would be appropriate to report the two services with separate codes. Once again, Blackham reminds us that payers may not agree.

Not Getting Stuck

Of course, no coder wants to see his or her practice left holding the bag for uncovered ultrasounds. According to ob-gyn practices from around the country, ob patients are increasingly expecting ultrasound to be part of the ob package. Further, some managed care providers and insurance companies are negotiating packages that include ultrasounds as part of the global package. How can ob-gyn practices protect themselves?

Practice managers, providers and coders need to look carefully at contracts and talk with payers about expectations concerning ultrasounds. In addition, practices need to be clear with patients about their responsibilities when it comes to uncovered ultrasounds. Lorence, states that her practice is very careful to make sure they arent stuck with uncovered ultrasounds. She says, If a patient doesnt have a medical diagnosis, than we have them sign a waiver.