Radiology Coding Alert

Question: A patient visits her obstetrician’s office for a repeat transabdominal ultrasound to measure fetal size and re-evaluate abnormalities found during the first ultrasound. The patient is 14 weeks pregnant and had an initial transabdominal ultrasound performed last week. The obstetrician documented the ultrasound results in the patient’s medical record.

How do I report this ultrasound procedure?

Kansas Subscriber

Answer: You’ll assign 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus) to report the ultrasound.

During the procedure, the provider performs a follow-up ultrasound to re-examine possible abnormalities from a prior ultrasound scan. The physician also measures the fetal size and amniotic fluid volume to evaluate how the fetus is growing.

You’ll also notice 76816’s descriptor doesn’t include trimester-related information. This means the code can be assigned for similar procedures performed throughout the patient’s pregnancy.

You can locate the code choices by searching the AMA CPT^® Index for Ultrasound > Obstetrical > Pregnant Uterus. Then you’ll turn to the Radiology section of the CPT^® code set to verify your code selection.

Modifiers need not apply: You won’t need to append modifier 26 (Professional component) to 76816 since the ultrasound and interpretation of the results were performed in the obstetrician’s practice.