Radiology Coding Alert

If your practice believes that all of your obstetric ultrasounds are "detailed," take note: CPT Codes 2003 specifies which anatomic evaluation elements you must document when billing 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and +76812 ( each additional gestation [list separately in addition to code for primary procedure]).

The new introduction to CPT's Obstetrical Ultrasound section advises physicians to report the new detailed ultrasound codes only if they evaluate all the standard ultrasound elements, plus several additional anatomic components.

"Our standard ob ultrasound includes head and abdomen circumference measurements, femur length, amniotic fluid and placenta assessment, four-chamber heart and three-vessel cord evaluations, cardiac and limb movement evaluations, and cervix length measurement," says Carrie Caldewey, RCC, CPC, office manager at Redwood Regional Medical Group in Santa Rosa, Calif.

"A detailed examination would include all of those factors, plus ventricle examination, specific organ aspects, information regarding limb or spine formation, and other information. The detailed instructions in CPT are fairly clear on how the two differ."

CPT 2003 also offers new postdescriptor advice, guiding coders to the appropriate add-on codes and modifiers. For instance, previous CPT editions instructed coders to use modifier -51 (Multiple procedures) for second and third fetal biophysical profiles (BPP, 76818-76819). This year, CPT recommends appending modifier -59 (Distinct procedural service) instead.

"Coders should also note that CPT 2003 explicitly states that if the practice performs a transvaginal examination in addition to a transabdominal nonobstetrical ultrasound exam, report 76830 (Ultrasound, transvaginal) in addition to the transab-dominal exam code (76856-76857)," says Melanie Witt, RN, CPC, MA, an independent coding consultant and educator in Fredericksburg, Va. "You will still have to append modifier -51 in all likelihood to the second scan."

CPT also revised existing codes to specify single gestations versus "each additional" gestation, fetal age, and transvaginal versus transabdominal approach. The following case studies should help physicians select the correct ultrasound code:

Case Study #1:

Ultrasounds Before and After Fetal Loss

A 26-year-old patient presents for a transvaginal ultrasound. The physician determines that the patient is six weeks pregnant with two fetuses in separate gestational sacs. The patient suffers from vaginal bleeding at week 15 and returns to the practice. A transabdominal ultrasound reveals that the patient lost one fetus. The practice performs a detailed anatomic examination of the remaining fetus, and the physician declares it healthy.

"For the initial visit, we would use American College of Radiology (ACR) guidelines to determine whether to use the standard transvaginal ultrasound code (76830) or an obstetrical transvaginal ultrasound code (76817)," Caldewey says. "The ACR dictates that a patient with an unconfirmed pregnancy even if pregnancy is later determined during the ultrasound warrants 76830. In this case, assuming the patient was not aware that she was pregnant, I would report 76830."

Note: Not all payers follow the ACR guidelines, so always request your carrier's regulations on when to use standard versus obstetrical ultrasound codes.

If the patient already knows that she is pregnant when she arrives for the ultrasound, report the new code 76817. Either way, report 651.03 (Multiple gestation, twin pregnancy, antepartum condition or complication), 640.93 (Unspecified hemorrhage in early pregnancy, antepartum condition or complication), 641.93 (Unspecified antepartum hemorrhage, antepartum condition or complication) or a combination of these ICD-9 codes as the diagnosis, depending on the physician's direction.

For the follow-up exam, 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). "The diagnosis code should be 651.33 (Twin pregnancy with fetal loss and retention of one fetus, antepartum condition or complication) for this visit," Caldewey recommends.

Case Study #2:

Repeat Ultrasound to Confirm Fetal Health

A 32-year-old pregnant patient presents for her initial transabdominal ultrasound. The radiology technician dates the fetus at 13 weeks, five days. The physician is concerned that the fetus'head size does not match its other measurements, so he asks the patient to return at week 17 for a more detailed ultrasound. During the patient's second ultrasound, the radiologist measures the fetus'vital organs, tests the heart and movement rates, measures amniotic fluid, and examines the head size carefully. He determines that the fetus is healthy."

I would code the initial ultrasound as 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)," Caldewey says. "The findings are a discrepancy in the head size versus other anatomical measurements (presumably the abdomen circumference and femur length), and I would therefore assign 653.83 (Disproportion of other origin, antepartum condition or complication) as the initial ultrasound diagnosis."

Because the radiologist found no abnormalities during the follow-up ultrasound, you should report 76816 for the 17-week visit. "Even though the practice performed a detailed exam, it was still a follow-up to the original exam, so 76816 is still the correct code to assign," Caldewey says.

Use 76815 for 'Quick-Look'Ultrasounds

CPT advises coders to report 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) for the "quick-look" exams "limited to the assessment of one or more of the elements listed in 76815."

The remaining new and revised obstetrical ultrasound codes are as follows: