Radiology Coding Alert

Question: The provider performs a transabdominal and transvaginal ultrasound of a fetus with a gestational age of 22 weeks. The provider documents a second gestational sac. What is the correct combination of CPT^® codes?

Colorado Subscriber

Answer: Traditionally, for a transabdominal and transvaginal examination of a fetus with a gestational age of 14 weeks or greater, you would apply codes 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) for the transabdominal ultrasound and 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) for the transvaginal ultrasound) for the transvaginal ultrasound.

In this case, however, since the physician identifies a second gestational sac, you will want to include the add-on code 76810 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester [> or = 14 weeks 0 days], transabdominal approach; each additional gestation [List separately in addition to code for primary procedure]). A common mistake when coding multiple gestations involving transabdominal and transvaginal imaging is to code an additional transvaginal ultrasound for the second gestational sac. In this example, you will only code 76817 once.

Disclaimer: The coding suggested for this example hinges on the fact that the physician documents all anatomical criteria necessary to reach codes 76805 and 76817. For example, in order to meet the criteria for code 76805, the provider must document each of the following anatomical sites in the dictation report:

• Determination of number of fetuses and amniotic/chorionic sacs;
• Measurements appropriate for gestational age (older than or equal to 14 weeks, 0 days);
• Survey of intracranial/spinal/abdominal anatomy, four-chambered heart;
• Umbilical cord insertion site;
• Placenta location and amniotic fluid assessment; and
• Examination of maternal adnexa (when visible).