Radiology Coding Alert

Check medical indication and what parameters your physician assessed.

Obstetric ultrasounds can leave you confused as routine ultrasounds differ from complex ultrasounds. You cannot report complex for just any indication for ultrasound. Experts advise how to clearly distinguish the two and submit correct claims.

What is a routine obstetric ultrasound? Your physician may typically perform a routine ultrasound in pregnant women, usually at 18-20 weeks of gestation. In fact, the American Congress of Obstetricians and Gynecologists (ACOG) maintain that physicians should include one complete ultrasound as a part of routine obstetric care. Your physician will perform any additional ultrasounds based on the medical necessity. “The Society for Maternal-Fetal Medicine (SMFM) has also determined that no more than 1 fetal ultrasound with detailed anatomic examination is necessary per pregnancy, per practice, unless there are extenuating circumstances with a new diagnosis,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA.

You must be certain to make the distinction between regular and detailed obstetric ultrasounds in your claims every time. If your practice undergoes an audit, incorrect coding may mean your payer could take reimbursement back.

Review Indications for Routine Ultrasounds

When a patient presents with suspected uterine or placenta abnormalities, you shouldn’t automatically leap to the conclusion that your physician had performed a complex ultrasound. These abnormalities are among the indications for a routine ultrasound. 

Indications: When your physician performs an ultrasound on an obstetrics patient in her second or third trimester, he may do this for one or several reasons. Besides gestational age, fetal weight, and fetal presentation, your physician may evaluate one or more of the following when performing an ultrasound:

• fetal growth
• uterine size (date discrepancies)
• fetal death
• suspected uterine abnormality 
• abnormal alpha-fetoprotein (AFP) 
• suspected poly/oligohydramnios 
• suspected abnormalities of placenta 
• vaginal bleeding/amniotic fluid leakage 
• follow-up of suspected fetal anomalies 
• patients with history of prior congenital anomalies.

Code a routine ultrasound based on the number of fetuses with 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 possibly +76810 (... each additional gestation [list separately in addition to code for primary procedure]). “You report code 76805 when your physician identifies only a single gestational sac in the second trimester.  You report code +76810 for each additional gestation in cases with twins or multiple gestations,” Hembree says. 

You should identify the reason for the scan using the appropriate ICD-9 code. If this ultrasound is a routine screening, you should use only V28.3 (Encounter for routine screening for malformation using ultrasonics). If the physician has reason to believe there is a problem with the fetus, use the 655 category code that identifies that reason. For instance, you might use 655.83 (Other known or suspected fetal abnormality, not elsewhere classified… antepartum condition or complication).

Test Yourself with This Scenario

Scenario: A 35-year-old patient presents at 18 weeks gestation with decreased amniotic fluid. The patient was referred for a routine ultrasound due to suspected renal malformations or abnormalities. You should report 76805.

If the same patient presents and is carrying twins at 18 weeks, your physician will perform a second ultrasound in addition to 76805, reported with add-on code +76810 (... each additional gestation [list separately in addition to code for primary procedure]).

Documentation requirements: According to Hembree, when your physician performs 76805/+76810, you should ensure the following documentation:

• number of fetuses and amniotic/chorionic sacs
• measurements appropriate for gestational age (older than or equal to 14 weeks 0 days)
• survey of intracranial/spinal/abdominal anatomy, four chambered heart, umbilical cord insertion site, and placenta location
• assessment of amniotic fluid
• exam of maternal adnexa when visible.
• Without these elements, you could be setting yourself up for an audit. 

Master Doc Requirements for More Complex US

When a patient has a history of a genetic disorder that can be adequately diagnosed by ultrasound exam, you can substantiate the use of a more detailed/targeted ultrasound with 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) and possibly +76812 (... each additional gestation [list separately in addition to code for primary procedure]). These codes are primarily for maternal fetal medicine (MFM) specialties. Other indications that will warrant the use of this more advanced ultrasound machine are:

• suspected fetal anomaly during level I exam
• severe intrauterine growth restriction (IUGR)
• maternal diabetes
• elevated AFP (serum or amniotic fluid)
• oligo/polyhydramnios
• two-vessel cord in level I exam
• multiple pregnancy
• fetal cardiac arrhythmia
• first-trimester exposure to drugs/chemicals.

Scenario: During a clinical obstetric evaluation, a patient was suspected of having a fetal anomaly and visited the physician for a detailed/targeted ultrasound. In this case, you would use 76811.

For each additional fetus, you should use +76812. These ultrasounds allow your physician to take more detailed measurements and assess any malformations. “You use +76812 in conjunction with 76811 and for each additional each additional gestation/fetus,” Hembree says.

Additional documentation requirements: When your physician performs 76811/+76812, you have to show that this detailed exam is medically indicated. “CPT® guidelines state codes 76811 and +76812 include all elements of codes 76805 and +76810 plus detailed anatomic evaluation,” Hembree says. So in addition to the requirements for 76805/+76810 listed above, your physician should also include the following elements:

• fetal brain/ventricles
• face
• heart/outflow tracts
• chest anatomy
• abdominal organ specific anatomy
• number/length architecture of limbs
• evaluation of umbilical cord and placenta.

Focus on 2 Differences

Here’s how you should separate detailed from routine ultrasounds.

The routine ultrasound code 76805 does not include a detailed fetal anatomic examination. This separates a routine ultrasound from a detailed/targeted one. But a detailed exam must be supported by medical need so just because the physician can perform a detailed exam, does not mean it is clinically indicated.

Also, keep in mind that a routine ultrasound that is always done at 18-20 weeks is NOT 76811. You’ll report 76811 for a specific reason (such as suspected fetal anomaly) and should consider it a second-level ultrasound that technicians perform on high-resolution special ultrasound equipment.