Radiology Coding Alert

Question: What are the rules surrounding documentation of amniotic fluid on an initial maternal fetal evaluation ultrasound (US)? Is the provider’s documentation of “free fluid” enough to meet the criteria listed in code 76801?

Arkansas Subscriber

Answer: Among the list of CPT^® elements needed to report 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), you’ll find the following pertaining to documentation of amniotic fluid:

• “Qualitative assessment of amniotic fluid volume/ gestational sac shape.”

However, it’s important to know that amniotic fluid is not visible on a fetal US until the patient is nearing the second trimester. Fortunately, that specific CPT^® element can be met so long as the radiologist documents the reason for the non-visualization of the amniotic fluid. In the American College of Radiology (ACR) Radiology Coding Source (March-April 2007), the ACR elaborates on this point:

• “When the pregnancy is in the first trimester (less than 14 weeks), the coder should remember that the requiredelements for CPT^® code 76801 will be those that are ‘appropriate for gestation’ and ‘visible.’ If any of the elements listed in the CPT^® code book are not able to be measured or are not visible, then the report should document that information in order to assign 76801.”

To your inquiry about the “free fluid,” if the provider documents free fluid at an initial pregnancy US (around seven or eight weeks), the amniotic fluid will not be visible, so the reference to free fluid should not be mistaken as documentation of amniotic fluid. Rather, the radiologist is documenting whether free fluid exists within the peritoneal cavity.