Question: How should I report a transvaginal ultrasound for a patient pregnant with twins? Oregon Subscriber Answer: You may be tempted to report 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) twice and append modifier -59 (Distinct procedural service), but try to resist. This is incorrect. You should report 76817 only once when the patient is pregnant with twins. A transvaginal ultrasound does not allow the technologist or physician to visualize each twin clearly, so the radiologist should use it only to identify the presence of twins, which is not significant extra work.