Radiology Coding Alert

Question: A patient presented with a history of a positive pregnancy test, but she complained of spotting over the previous three days. The physician ruled out an ectopic pregnancy, and the uterus was empty. Should we report the obstetric ultrasound codes or the nonobstetric ultrasound codes?

Florida Subscriber
Answer: If the physician previously confirmed the pregnancy by any method (such as a pregnancy test or prior ultrasound), you would probably report one of the following pregnant ultrasound codes, depending on the documented approach:

  76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation

  76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal.
It is key that a physician previously diagnosed the patient as pregnant if the patient determined pregnancy through a home test, the pregnancy has not been "diagnosed," and the visit would therefore not qualify as a pregnant uterus ultrasound.
  The answers for You Be the Coder and Reader Questions were reviewed by Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Dallas, Ga; and Gary S. Dorfman, MD, FACR, FSIR, representative to the AMA's CPT Advisory Committee.