Radiology Coding Alert

Question: I code ultrasounds at our multispecialty clinic. The physician ordered an ultrasound in gestation week 12 to confirm the presence of triplets. How should I report this service?

Connecticut Subscriber

Answer: You should report:

• fetus 1: 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
• fetus 2: +76802 " ... each additional gestation (list separately in addition to code for primary procedure)
• fetus 3: +76802-59 " ... Distinct procedural service.

According to CPT guidelines, 76801 and +76802 include the following:

• determining the number of gestational sacs and fetuses taking gestational sac and fetus measurements
• surveying visible fetal and placental anatomic structure providing qualitative assessment of amniotic fluid volume and gestational sac shape
• examining the mother's uterus and adnexal structures.

Next visit: For each subsequent ultrasound during the patient's pregnancy, you should normally use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., 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).

Because 76816 states "per fetus," you should report 76816 with modifier 59 for each additional fetus examined in a multiple pregnancy, CPT says. For example, with triplets you would use 76816, 76816-59, and 76816-59.

-- The answers for You Be the Coder and Reader Questions were reviewed by Michele Midkiff, CPC-I, PCS, RCC, executive director of Coding Affiliates Inc., an interventional and  eurointerventional radiology coding service in Mountain View, Calif.