Radiology Coding Alert

Question: We perform daily monitoring sonograms and report CPT 76830 for them. Should we include a written description of the service that we perform and the conclusion with the film? If so, which specific details should we incorporate into the write-up, and would the insurer require this for each daily sonogram?

New York Subscriber

Answer: To report 76830 (Ultrasound, transvaginal), you must maintain a formal written report that documents the ultrasound's medical necessity, along with the ultrasound findings.

According to the American Institute of Ultrasound in Medicine, the physician's documentation not only must be complete but should also detail the findings for the uterus, adnexa, cul de sac and cervix. If the physician simply monitors follicle development, some payers will recode your 76830 claim with 76857 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; limited or follow-up [e.g., for follicles]), even though the doctor performs the scan transvaginally rather than transabdominally.

Because the relative value units for the transvaginal code are higher than those for the limited scan -- 2.57 for 76830, and 2.17 for 76857 (totaling about $15 more for 76830) -- and because the carrier expects the radiologist to examine more details to report 76830, you should consider appending modifier -52 (Reduced services) to the transvaginal code. Without the modifier, your insurer may cite you for coding a higher level of service than the physician documented.

Although you don't list your patient's diagnosis, you should ensure that daily sonograms are medically necessary for your patient because this would be an uncommon circumstance.