Ob-Gyn Coding Alert

Question: My ob-gyn is performing ultrasounds for reasons like “repeat anatomy.” In other words, he’s doing them for no reason other than that he couldn’t visualize certain areas because the patient’s pregnancy was too early on for the first one. Although I have tried to convince my ob-gyn otherwise, he says there is a diagnosis code out there that states “repeat anatomy.” What is he talking about?

New York Subscriber

Answer: No, you won’t find any such diagnosis code.

A repeat is a follow-up exam, and you should report that with 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).

The diagnosis is the same as the first one the ob-gyn did. This might be to complete a scan for a malformation (V28.3, Screening for malformation using ultrasonics) or to complete a fetal anatomic survey (V28.81, Encounter for fetal anatomic survey) when he initially did not find any problem.