Radiology Coding Alert

Question: A patient came into our radiology practice for her 1st ultrasound (US) after finding out she is pregnant. The radiologist performed the obstetrical ultrasound and discovered the patient is carrying twins. After the obstetrical US, the physician documents all the required criteria in the findings of their report.

What code(s) should I use to document the ultrasound?

Arizona Subscriber

Answer: In this scenario, you’ll start with CPT^® code 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) to report the patient’s 1st trimester US. You’ll then need to use add-on code +76802 (…; each additional gestation (List separately in addition to code for primary procedure)) for the ultrasound of the additional gestation sac.

The guidelines for 76801 and +76802 require determining the number of gestational sacs and fetuses, gestational sac/fetal measurements that match the gestation period, a survey of visible fetal and placental anatomic structure, an assessment of amniotic fluid volume and gestational sac shape, and an exam of the adnexa and maternal uterus.

Important: CPT^® code +76802 is an add-on code, which means payers will not reimburse your practice if the code is reported without 76801 for the 1st gestation.