Radiology Coding Alert

Question: We performed an ultrasound on a patient with a positive pregnancy confirmed by a physician, but the uterus was empty and there was no evidence of ectopic pregnancy. Should I report an obstetric or nonobstetric ultrasound?

Montana Subscriber

Answer: If a physician previously confirmed the pregnancy, you should report an obstetric ultrasound, such as 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).

An October 2001 CPT Assistant article, published by the AMA, states that for a patient with an established pregnancy diagnosis with signs and symptoms that are possibly pregnancy-related and require an ultrasound, you should report obstetrical ultrasound codes 76805-76815, "even if the outcome of the procedure is that the patient is now not pregnant or has an ultrasonic diagnosis that might be construed as being independent of the pregnancy."

-- The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.