Radiology Coding Alert
Overcome Confusion When Reporting Ob Ultrasounds
These problems have been exacerbated in recent years because ultrasounds (U/S) are being ordered more frequently than ever. Fifteen or 20 years ago it was routine for a primary care physician or obstetrician to order a single ultrasound during pregnancy (V22.2, normal pregnancy; pregnant state, incidental). More recently, two are often performed -- one in the first trimester, and a second later in the pregnancy. This trend has opened the door to even greater confusion -- and even greater chances for denial and lost revenue.
"Ultrasound is often done at eight or 10 weeks to get an overall picture of the pregnancy," explains Pat Kirkham, RDMS, sonographer with Randallwood Radiology, a private practice of three radiologists in St. Charles, Ill. "This study is something of a screening and helps rule out some of the common prenatal defects. This stage of development is also the time when we can most accurately measure the fetus to determine the date of gestation." The second U/S, frequently performed at 18-22 weeks, provides greater detail about the condition of the fetus (e.g., whether organs are developing along a normal timeline).
Ob ultrasounds may be conducted in one of two ways. The more traditional approach is transabdominally, where the patient is asked to fill her bladder, and a transducer is moved across her lubricated abdomen. Ultrasonic waves bounce off the bladder to create images of the uterus, its contents and surrounding organs. As an alternative, U/S may be conducted transvaginally, where the probe is inserted into the vagina. "The transvaginal approach provides the sonographer with a different perspective of the organs being studied," explains Jacqui Szymanski, RT (R), M, practice administrator for Associated Imaging Specialists in Elgin, Ill. "The different vantage point means that the images produced are much more detailed."
Match Transabdominal Code With Study
Four transabdominal codes are available:
The American College of Obstetricians and Gynecologists (ACOG) defines the complete study as primarily an anatomical evaluation. The fetal component includes head measurements and an examination of the neck, abdomen, chest, limbs and internal organs. Fetal life signs -- heart rate, breathing and movement -- are also noted. However, because the fetus is not developed sufficiently during the first trimester to allow for a full evaluation, many believe that this code should not be used before 12 weeks gestation.
The maternal evaluation includes the size and position of the uterus, placental and cord location, and an assessment of any abnormalities that might affect the pregnancy. "For instance," Kirkham says, "the age when women become pregnant has increased over the past few years and means there is a greater risk for uterine fibroid tumors (218.9, leiomyoma of uterus, unspecified). A complete ultrasound will help determine if fibroids are present and how they might affect the pregnancy."
Code 76810 describes a complete service and similar evaluations but is reported when the mother is carrying multiple fetuses (e.g., 651.03, multiple gestation; twin pregnancy; antepartum condition or complication).
Limited, Follow-Up Codes
Many coders report confusion when deciding when to assign 76815 and 76816. Szysmanski notes that a limited U/S is most often performed when only some of the evaluations conducted are done during a complete study. The limited code is used most often to report U/S evaluations performed during the first trimester, when the fetal maturity is insufficient to allow a complete U/S.
"In other instances, there may be some concern that the baby is in trouble, so a limited U/S will be done to determine heart rate and breathing," Szysmanski says. "Or, the mother may be bleeding (e.g., 640.93, hemorrhage in early pregnancy; unspecified; antepartum condition or complication) so an U/S might be done to pinpoint the problem." Limited ultrasound may also be performed if a second heartbeat is heard during a routine OB visit. Code 76815 would be reported for fetal demise (e.g., 656.43, intrauterine death, antepartum condition or complication) as well as for an emergency during delivery that results in fetal distress.
"There are many reasons why a complete ultrasound [76816] might be repeated," Kirkham says. "During an initial study, for example, the radiologist may have noted low-lying placenta (641.03, placenta previa without hemorrhage; antepartum condition or complication) or that the amount of amniotic fluid seemed inadequate (658.03, oligohydramnios; antepartum condition or complication). It would not be unusual for an ultrasound to be performed again later in the pregnancy to monitor conditions like these. Repeat evaluations may also be done during high-risk pregnancies, when the mother is of advanced age or has a history of miscarriages, for instance."
Transvaginal Same Day as Transabdominal
Although it may be performed alone, it is common for a transvaginal ultrasound (76830, echography, transvaginal) to be performed during the same session as a transabdominal study, particularly early in the pregnancy, Kirkham says. "I have found that most transvaginal ultrasounds are done in the first trimester. It provides a wealth of information." The sonographer may begin with a transabdominal approach, but may have difficulty visualizing all of the fetus' organs. In these cases, both the transabdominal and the transvaginal codes should be assigned, e.g., 76815 and 76830-51. Modifier -51 (multiple procedures) is added to the transvaginal code to identify it as the secondary, additional service.
However, the American Medical Association (AMA) has ruled to the contrary, noting that each approach comprises a distinct study and that the services performed for the transvaginal echography are not included as part of the ob examination. In addition, both are necessary to making accurate diagnoses in many instances. If a payer denies the claim, coders should appeal, citing the AMA's position and, if necessary, request documentation from AMA's CPT Information Services.
Coding Biophysical Profiles With Ob U/S
During pregnancy, fetal biophysical profiles (76818, fetal biophysical profile; with non-stress testing, and 76819, ... without stress or non-stress testing) may also be performed -- either alone or with any of the ob echographic procedures. Each may be reported with the appropriate codes, appended with modifier -51 as necessary.
The fetal biophysical profile is much more detailed than the other ob studies. While the ob U/S evaluates the size of the fetus, ensures all body parts are developing properly and measures structures, the fetal biophysical profile goes beyond that to determine if functions are normal. This study will be ordered when underlying conditions are uncovered that might jeopardize the fetus (e.g., unusually slow or rapid growth of the fetus, or unusual sounds heard during fetal monitoring). These must be clearly documented in the patient record to justify multiple exams during the same service period.
Five specific areas must be examined, recorded on videotape, and documented in the patient record during a 30-minute fetal biophysical profile: fetal breathing movement, gross body movement, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. Because these fetal functions cannot be evaluated early in the pregnancy, this service can be provided and coded only after the first trimester.
CPT includes several other specialized fetal ultrasound services (e.g., 76825, echocardiography, fetal, cardiovascular system, real time with image documentation [2D], with or without M-mode recoding). These studies are most often provided and interpreted by physicians with special training in obstetric ultrasound and fetal anomalies.
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