Radiology Coding Alert

Question: In a patient who reported for high blood pressure at a gestational age of 28 weeks and 5 days, our radiologist did a biophysical profile. The report of the biophysical profile reads as follows:

“The placenta is located along the anterior wall. It is heterogeneous in echotexture, grade II. The AFI is 5.4 cm, which is low. Fetal motion noted by the technologist. Heart rate is 147 beats per minute. Intrauterine hypoechoic area seen anteriorly within the uterus measures about 2 cm in size and a second similar sized hypoechoic area is located within the uterus. Both findings are presumed fibroids. They are nonspecific findings, however.”

The biophysical profile was scored a perfect 8 out of 8. Please suggest the appropriate CPT® code and ICD-9 code.

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Answer: You report CPT® code 76819 (Fetal biophysical profile; without non-stress testing) for the biophysical profile described. Code 76819 requires a maximum score of eight with four listed components. These components include fetal breathing, fetal movements, fetal muscle tone, fetal heart rate, and amniotic fluid. The procedure is performed without non–stress testing. You report code 76818 (Fetal biophysical profile; with non-stress testing) if non-stress testing was done. You also report the ICD-9 code 796.9 (Other nonspecific abnormal findings).

Fetal biophysical profile assessments for the second and any additional fetuses should be reported separately by using CPT® code 76818 or 76819 with modifier 59 (Distinct procedural service).

More about biophysical profile: A fetal biophysical profile is a test that is used to quantify fetal well–being. It uses ultrasounds to measure variables like fetal breathing, fetal movement, fetal tone, and amniotic fluid volume. A non–stress test is done to assess fetal heart rate. Each of these five variables is given a score of zero or two, for a potential total score of ten.