Radiology Coding Alert

Ultrasounds:

Identify OBUS Codes by Analyzing Anatomical Requirements

Published on Tue Feb 21, 2023

Hint: Don’t report 76811 before 76805 takes place.

The patient’s trimester, condition, and number of gestations all factor into obstetric ultrasound (OBUS) code selection, but they’re not the only elements you need to pay attention to. The CPT^®guidelines list several criteria the provider needs to document before you can assign an OBUS code.

Here’s what to look for in the documentation to code OBUS procedures correctly.

Figure out What is Visualized in the First Trimester

Scenario: A patient who is 12 weeks pregnant comes in for an OBUS. During the visit, the ultrasound technician discovers the patient is carrying twins. The technician compiles their report.

You’ll assign the following CPT^®codes to report the ultrasound procedure:

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)
+76802 (… each additional gestation (List separately in addition to code for primary procedure))

You’ll assign 76801 to report the transabdominal OBUS of the patient in her first trimester. This code is designated for the evaluation of the mother and the first gestation of her pregnancy. “This is, of course, the less-than-14-week scan of a pregnant uterus. This is an interesting scan because a provider never knows what they’re going to see. The scan can let a provider know if someone is actually pregnant, or if the pregnancy has failed, or if the pregnancy has become nonviable,” said Tyler Griffeth, MOL, CPC, CPRC, coding consultant for Intermountain Health Care in an AAPC webinar.

At the same time, the provider can also see more than one pregnancy. If the provider visualizes multiple pregnancies and documents this information (like in the scenario above), you’ll assign add-on code +76802 to report the patient’s second gestation.

“Each add-on code is listed separately in addition to the primary procedure for each additional gestation, or in other terms, each additional baby in the uterus such as twins. The primary procedure code would be for twin A and the add-on code for twin B,” says Grabiela Juarez, CPC, CPMA, COC, AAPC-Approved Instructor, revenue cycle specialist with Sceptre Management and owner of Medical Coding Vida Academy in Salt Lake City, Utah.

Important: The guidelines prior to the OBUS codes in the CPT^®code set lay out what criteria need to be visualized and documented for you to report 76801/+76802.

To report these codes, the provider’s documentation needs to include:

Determination of the number of gestational sacs and fetuses,
Gestational sac/fetal measurements appropriate for gestation (younger than 14 weeks 0 days),
Survey of visible fetal and placental anatomic structure,
Qualitative assessment of amniotic fluid volume/ gestational sac shape, and
Examination of the maternal uterus and adnexa.

CPT^® guidelines state, “Report should document the results of evaluation of each element described above or the reason for nonvisualization.” This means that the provider’s documentation needs to explicitly list each item or indicate why the provider was unable to see it. Query the provider if any of the elements are missing or the report doesn’t include why the provider was unable to view the elements.

Make Sure the Pregnancy Reaches 14 Weeks Before Reporting 76805

Scenario: A patient, who is 20 weeks and 5 days pregnant with one fetus, comes into your radiology practice for a transabdominal OBUS to evaluate the mother and fetus. The technician performs the procedure and compiles their report.

You’ll choose from the following codes for an OBUS at 14 weeks and beyond:

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)
+76810 (… each additional gestation (List separately in addition to code for primary procedure))

Depending on what the provider sees, evaluates, and documents in their report factors into your code selection.

According to CPT^®guidelines, you’ll assign 76805 for the OBUS if the provider documents the following criteria:

Determination of the 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,
Placenta location and amniotic fluid assessment, and
When visible, examination of maternal adnexa.

Once again, the provider should document the reason for nonvisualization if any of the above elements cannot be evaluated, for example, if the baby has grown and is blocking the view of the maternal adnexa.

Assign 76811 When Further Evaluation is Needed

“Code 76811 includes more detailed images of the fetal anatomy as well as a more specific evaluation of those structures. It’s important to note that the detailed scan is not based on gestational age. This type of scan is typically done to evaluate a fetus who had an abnormality identified on a previous scan,” Griffeth said.

Scenario: A patient who is pregnant with one fetus, comes into your radiology practice for her 20-week appointment. During the OBUS, the provider notices an anomaly and requests the patient return the next week for a follow-up US.

This scenario is common. You’d report 76805 to report the 20-week US appointment if all the elements for the code are documented. You’d then assign 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) after the follow-up appointment.

Since 76811 is a more detailed examination of the fetus, you’ll need to ensure the appropriate information is documented or the reason for nonvisualization is documented. Code 76811 includes all the elements from 76805/+76810, as well as the following criteria:

Detailed anatomic evaluation of fetal brains/ventricles,
Face,
Heart/outflow tracts and chest anatomy,
Abdominal organ-specific anatomy,
Number/length/architecture of limbs,
Detailed evaluation of the umbilical cord and placenta, and
Other fetal anatomy as clinically indicated (not nuchal translucency)

Of course, you’ll need to include any documented fetal anomalies identified from the 76805 scan as the medical necessity for 76811. “If certain criteria are met for identified or suspected abnormalities of the mother’s reproductive structures, fetus(es), placenta, fetal viability, or other high-risk conditions, then medical necessity may be met for certain services,” Juarez says. As a best practice, you’ll want to review your individual payer preferences for what conditions may show medical necessity.