Radiology Coding Alert

Question: I recently started coding for ultrasounds at a multispecialty clinic. Is there a standard diagnosis code to use with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation)?


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Answer: If the referring physician indicates that it is a routine US exam, you should report the appropriate pregnancy supervision code:
• V22.0--Supervision of normal first pregnancy
• V22.1--Supervision of other normal pregnancy
• V23.x--Supervision of high-risk pregnancy.
 
If the US is to screen for abnormalities, you should select from the following:  

• V28.3--Screening for malformation using ultrasonics
• V28.4--Screening for fetal growth retardation using ultrasonics
• V28.8--Other specified antenatal screening
• V28.9--Unspecified antenatal screening.
  
If the exam is being performed due to signs, symptoms, or known abnormalities (rather than for screening), you should select a code from the OB chapter of ICD-9. Example: Report an US performed on a pregnant patient due to gestational diabetes with 648.83 (Abnormal glucose tolerance; antepartum condition or complication).

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.; and Gary S. Dorfman, MD, FACR, FSIR.