Ob-Gyn Coding Alert

Question: What is the CPT® code for initial anatomy ultrasound at 15 weeks gestation and the CPT® code for the follow-up “f/u” anatomy ultrasound?

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Answer: You should report CPT® code 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) to describe the initial screening ultrasound. This code is specific for a transabdominal U/S performed after the first trimester and includes measurements and evaluation of fetal anatomy appropriate for the gestational age.

You should report 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus) for the subsequent U/S if the physician did this to follow-up on a previously discovered condition. The CPT® code descriptor for 76816 includes examples of possible uses including “re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan.”