Iowa Subscriber
Answer: You may code for both ultrasounds as long as they are both medically necessary and ordered by the gynecologist.
Report 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76830 (Ultrasound, transvaginal). Depending on your payer's rules, you may need to append modifier 51 (Multiple procedures) to 76830.
Why: CPT guidelines say that if you perform a transvaginal examination in addition to a transabdominal nonobstetric ultrasound, you should report 76830 in addition to the appropriate transabdominal exam code. Remember: CMS requires that the treating physician--in this case, the gynecologist--order diagnostic tests. The request and report should convey the medical necessity for both exams.