Radiology Coding Alert

Tackle these case studies involving multiple gestations.

Obstetrical ultrasound (US) coding is a staple service of many diagnostic radiology providers. From the coder’s perspective, this means you typically work through more than enough reps on a day-to-day basis to have the coding fundamentals down pat. However, for US examinations involving multiple gestations, you may find yourself taking a pause to confirm all the coding elements are in their right place.

Today, you’re going to cover a few common scenarios in order to ensure you don’t miss a beat the next time you get working on an obstetrical US with one or more documented gestations.

Put your skills to the test by working through the following three clinical scenarios.

Associate Modifier 59 With Multiple Gestation Follow-Up Services

Scenario: A patient carrying triplets at 19 weeks is reexamined three weeks following detection of an abnormality on a routine obstetrical US. The provider performs a repeat complete obstetrical US, meeting all the same criteria as the exam three weeks prior.

The patient is returning three weeks following a planned second trimester obstetrical US. You would report the initial service (three weeks prior) as 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation) and +76810 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)) x 2 units.

In making your coding determination for the current visit, you should not consider whether the follow-up exam meets all the criteria needed in reporting 76805. According to Clinical Examples in Radiology (Spring, 2016), a follow-up exam performed for follow-up of an anatomical anomaly should be reported as 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, 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). Despite the fact that the radiologist performs a repeat procedure as compared to the prior 76805 service, the guidelines instruct you to report any follow-up obstetrical examination for reevaluation or suspected prior anomaly detection as 76816. Furthermore, parenthetical notes instruct you to append modifier 59 (Distinct procedural service) to the second and third 76816 codes on the claim to indicate the second and third fetus.

Keep in mind: There is no definitive set of criteria that needs to be met for 76816 reporting the same way you’d report a complete obstetrical US service. The provider may perform an exam that closer resembles a “quick look” service, such as 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses). “However, keep in mind that you will report 76815 exclusively for obstetrical US services that do not meet the given criteria for codes 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) or 76805 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation),” explains Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania.

Know Which Services Include More Than 1 Gestation

Scenario: A patient carrying twins at the 19-week mark presents for a routine obstetrical US in addition to a transvaginal US. The radiologist documents all the necessary criteria in the findings of the report.

After confirming all the respective criteria are met for a patient in her second trimester undergoing a complete obstetrical US, you may report 76805. You will report +76810 for the second gestation. You will report the transvaginal US with 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal). CPT^® Assistant (November 2011; Volume 21: Issue 11) states that 76817 “includes evaluation of embryo(s) and gestational sac(s) and evaluation of maternal uterus, adnexa, and/or cervix.” This means you will report one unit of 76817 regardless of the number of embryos or gestational sacs.

Consider These Fetal Biophysical Guidelines

Scenario: A patient carrying triplets in the second trimester presents for a limited obstetric US with a fetal biophysical profile. The radiologist documents a heart rate of 149 bpm and tabulates a biophysical profile score of 8/8. All necessary parameters for a complete biophysical profile were measured.

First, it’s important to note that a fetal biophysical profile with non-stress testing isn’t typically performed by radiologists. Documentation of a fetal heart rate is not sufficient for 76818 (Fetal biophysical profile; with non-stress testing) reporting.

A limited obstetrical US (“quick look”) may be reported separately alongside code 76819 (…without non-stress testing); however, you must have documentation of two separate dictation reports. If the fetal biophysical profile dictation report includes documentation supporting code 76815, then you should request an addendum from the radiologist before billing for each service separately. Without a separate report, you will not report code 76815 separately.

If you have documentation to support both services, you should adhere to the 76819 parenthetical notes which advise you to append modifier 59 to 76819 for each additional fetus. Code 76815, however, is reported once regardless of the number of fetuses imaged. Therefore, you will report 76819, 76819-59, 76819-59, 76815.