Ob-Gyn Coding Alert

Question: I billed 76801 with V72.42 to Anthem and received a denial for -not medically necessary.- My ob-gyn's notes indicate he performed the ultrasound for dating purposes. What diagnosis should I use?

Colorado Subscriber

Answer: Go back and read your ob-gyn's notes. If this is a routine screening, you can choose between V28.3 (Antenatal screening for malformation using ultrasonics), which includes -routine fetal screening not otherwise specified,- or V28.89 (Other specified antenatal screening) which you would use to report -other- reasons for antenatal screening.

As you have indicated, you billed 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [< 14 weeks 0 days], transabdominal approach; single or first gestation). The ob-gyn did not also report a fetal survey, so V28.81 (Encounter for fetal anatomic survey) would not apply to this situation.

On the other hand, if he documented a uterine sizedate discrepancy in the record, you can go with 649.63 (Uterine size date discrepancy; antepartum condition or complication). Your ob-gyn's documentation must specify this information.

Tip: Review your copy of Anthem's coverage criteria (http://www.anthem.com/medicalguidelines/va/f3/s10/t1/pw_ad081088.pdf). You-ll see that V72.42 (Pregnancy examination or test, positive result) is not an approved diagnosis code for a routine screening ultrasound. Although you should never choose a code simply to secure reimbursement, you should look at your ob-gyn's documentation for a documented diagnosis (if any) that Anthem includes on this list.