Radiology Coding Alert

Understanding the American Medical Associations (AMA) position on certain ob-gyn ultrasounds conducted on the same day can be key to appealing a denial.

One major issue revolves around whether or not transvaginal ultrasounds (CPT 76830 , echography, transvaginal) may legitimately be performed on the same patient on the same day that a standard pelvic ultrasound is conducted (using the transabdominal approach). Although the AMA has clearly indicated that it is frequently appropriate to conduct both ultrasounds on a patient during the same session or on the same day, some carriers are refusing to pay for the transvaginal approach.

Because transabdominal and transvaginal approaches allow a radiologist to view many of the same organs, payers sometimes argue that there should be no need for both to be performed the same day on the same patient. Their rationale is based on definitions such as the one that appears in the American College of Radiologys (ACR) Ultrasound Guidelines, which describe a transabdominal pelvic ultrasound as studying the uterus, ovaries and adnexa. The transvaginal approach is described as examining the uterus, endometrium, ovaries and adnexavirtually the same organs. Other payers argue that transvaginal echography is included as part of a complete pelvic ultrasound examination.

The AMA has stated that the two approaches describe distinct studies and that the services performed for the transvaginal echography are not included as part of the pelvic ultrasound examination. Both are necessary to making accurate diagnoses in many instances.

Although both types of ultrasound view mainly the same organs, the transvaginal approach allows a more precise field for examination, explains Rob Levin, CHBME, chief operating officer for Billing Solutions Inc. in Newtown, Pa., a firm that provides medical billing services to one of the countrys largest ultrasound companies. You can visualize more detailed anatomy, but there is some sacrifice due to a narrower field of view.

Two Services, Two Codes

A patient may be referred for an ultrasound because of unusual menstrual bleeding (626.2). A standard transabdominal pelvic ultrasound is performed and the technician identifies a small uterine mass that may be contributing to the womans condition. However, he is unable to get a clear view because of the location of the mass. He then utilizes a transvaginal approach to get a more precise image of the abnormality. Under these circumstances, the study would be assigned 76856 (echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76830-51. The -51 modifier (multiple procedures) is added to describe the transvaginal ultrasound as the secondary, additional service.

Another typical example of a transvaginal approach occurs when women are in the early stages of pregnancy, says Levin. During the first trimester, the fetus is so small, it may be difficult to visualize using a transabdominal approach, he points out. The transvaginal ultrasound visualizes anatomy that may not be visible utilizing the transabdominal approach (i.e. five- to seven-week pregnancy). Later in the pregnancy, when the fetus is larger, the transabdominal approach is usually adequate by itself, unless evaluation of the lower uterine segment (cervix) is of importance.

In addition to 76856, the codes that apply to pelvic ultrasounds using a transabdominal approach include: 76805 (echography, pregnant uterus, B-scan and/or real time with image documentation; complete [complete fetal and maternal evaluation]) and 76810 (complete [complete fetal and maternal evaluation], multiple gestation, after the first trimester).

It is legitimate to assign 76830 in addition to one of these codes in instances where both approaches are used, Levin notes. But coders need to be aware that there are payers who will refuse to pay for the transvaginal ultrasound. If this occurs, coders should appeal the denial, citing the AMAs position and, if necessary, request documentation from AMAs CPT Information Services.

Assigning Fetal Biophysical Profile Codes Requires Specific Documentation

The second significant area of concern involves the documentation required to justify a fetal biophysical profile, in addition to standard obstetric ultrasound studies of a pregnant uterus. Coders need to be aware of the stringent criteria that need to be dictated and reported in the patient record to justify these chargesand thereby receive the reimbursement to which they are entitled.

Similarly, the AMA has determined that the fetal biophysical profile (76818) may be performed in conjunction with any of the pregnant uterus echographic procedures (76805-76816), and that it is appropriate to report each individual procedure with individual codes to identify the total number of services provided.

The AMA also points out that the fetal biophysical profile identifies elements different and distinct from pregnancy uterus ultrasound. The specific differences must be documented in the patient record to justify multiple exams during the same service period.

This is where problems may occur, cautions Richard Brebner, BS, RDMS, RDCS, RVT, vice president and technical director for Ultrasound Services Inc., which provides diagnostic ultrasound services to practices in Pennsylvania, New Jersey and Delaware. There seems to be a growing trend that physicians order a fetal biophysical profile with every pregnancy. But there should be underlying conditions to justify this exam, and sonographers need to make sure they document the study, which is very detailed. These conditions may include maternal history of miscarriage (646.3, habitual aborter), unusually slow or rapid growth of the fetus (656.5, poor fetal growth) or unusual sounds heard during fetal monitoring (659.7, abnormality in fetal heart rate or rhythm).

A typical complete obstetric ultrasound, Brebner points out, is intended to check the size of the fetus, to ensure all body parts are developing properly, and to measure various structures, like the head, body and limbs. The fetal biophysical profile goes much farther than that, to determine if various functions are normal.

Correct Fetal Biophysical Profile Coding Requires Five Areas of Documentation

To be thorough, five specific areas must be examined, recorded on videotape and documented in the patient record during a 30-minute fetal biophysical profile, Brebner says.

1. Fetal breathing movement. The probe is positioned transabdominally on the fetus and the technician must record at least one 30-second episode of inhalation and exhalation during the course of the profile. You must be able to see the babys breathing motion, Brebner says. This is not something you would specifically focus upon during a typical ultrasound.

2. Gross body movement. The sonographer must observe and record at least three discrete body or limb movements during a minimum of 30 minutes. We look for the baby to stretch, turn or exhibit various forms of motion, he explains. These have to be separate episodes of activity and do not include several elements of one continuous movement.

3. Fetal tone. This portion of the profile identifies at least one episode of active muscle extension and the subsequent return to a relaxed statelike a fist opening and closing, Brebner says. This is not a typical standard for a pregnancy ultrasound, but it is a specific behavior you must record to justify the fetal biophysical ultrasound.

4. Reactive fetal heart rate. During this minimum 30-minute observation, the sonographer must observe and record at least two episodes indicating an increase in the babys heart rate. This usually occurs when the baby moves, and you need to document that the babys heart rate increases at least 15 beats per minute for at least 15 seconds, compared to the heart rate when the baby is at rest.

5. Qualitative amniotic fluid volume. The sonographer must be able to measure at least one pocket of amniotic fluid in the mothers abdomen, measuring at least one centimeter in two perpendicular planes. This is important information to record, Brebner says, since the amniotic sac serves as a temperature control for the fetus, acts as a shock absorber to keep the fetus safe, and is particularly important for fetal breathing and well-being.

Different laboratories have different standards that describe normal activity during a fetal biophysical profile, Brebner adds, but these five standards must be documented conscientiously in all circumstances in order to justify coding the service. A sonographer might casually notice these elements during a pregnant uterus ultrasound, but these factors are specifically examined when a profile is done.