Radiology Coding Alert

Learn how to differentiate codes 76811 and 76812.

Obstetric ultrasounds may be a routine procedure in your radiologist’s practice. Here is how you can earn for every ultrasound and each element of every examination.

Sort Out Multiple Ultrasound Codes

Invariably, multiple-gestation pregnancies mean multiple ultrasounds. Generally, your radiologist may be doing obstetric ultrasounds to show viability, the number of fetuses, fetal position, amniotic fluid volume, fetal measurements, placental location, and fetal weight estimation and to allow basic anatomical review. In this case, you must choose the codes based on fetal age:

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)

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).

“CPT^® 76801 is used to report a complete first trimester (less than 14 weeks) obstetric ultrasound and CPT^® 76805 is used to report a complete second or third trimester obstetric ultrasound,” says Christy Hembree, CPC, Team Leader, Summit Radiology Services, Cartersville, GA. “For a second or third trimester ultrasound, the pregnancy has progressed enough that more information about the fetus may be obtained from the study. Therefore, there are more documentation requirements than a first trimester ultrasound.”

Example: You may read that your radiologist does an ultrasound in gestation week 12 to confirm the presence of triplets. “In this case, assuming all the element for a first trimester OB ultrasound are documented, the correct CPT^® codes for an ultrasound in gestation week 12 with the presence of triplets are CPT^® 76801, +76802, and +76802,” says Hembree. “CPT +76802 is an add-on code to use for each additional gestation/fetus during the first trimester.”

Hembree explains the documentation required for a first trimester ultrasound. The following are important elements:

1.     Number and description of gestational sacs and fetuses

2.     Appropriate fetal measurements for gestation (i,e., fetal pole, crown-rump length)

3.     Survey of developing placental structure/ yolk sac

4.     Qualitative assessment of amniotic fluid volume

5.     Examination of maternal uterus/ adnexa

“If these requirements are not met then a limited OB ultrasound code may be reported, CPT^® code 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], 1 or more fetuses),” says Hembree. “This would be your only code because it includes evaluation of one or more fetuses.”

Watch for More USG Examinations

For each subsequent ultrasound during the patient’s pregnancy, you should normally use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., 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).

According to CPT^®, you can “report 76816 with modifier 59 (Distinct procedural service) for each additional fetus examined in a multiple pregnancy.” For example, with triplets you would use 76816, 76816-59 and 76816-59.

On the other hand, if you perform all the elements associated with a more complex ultrasound code -- such as a detailed fetal anatomic examination in addition to a full fetal and maternal evaluation -- because of high risk or other factors, you should report those codes instead. In this case, for a multiple gestation, you would use 76811 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) for the first fetus and +76812 (... each additional gestation [list separately in addition to code for primary procedure]) for each additional fetus.

Catch this clue: Codes 76811 and 76812 may require more sophisticated equipment and the expertise of a maternal-fetal medicine physician, experts say. Office-level equipment may not be able to obtain the necessary detailed imaging. The detailed ultrasound exams must also be medically indicated. For example, your physician might evaluate a patient if her pregnancy has an elevated risk of congenital abnormalities of fetal development (birth defects).

“To code CPT^® 76811 your report must document all the elements necessary for code 76805, and then adds detailed evaluation of the fetal anatomy, specifically the brain/ventricles, face, heart/outflow tracts, specific abdominal organs, all of the limbs, and umbilical cord/placenta,” says Hembree. “This exam is often performed for elevated risk of birth defects. CPT^® +76812 is an add-on code that describes each additional fetus evaluated.”

Tackle Transvaginal Ultrasounds

Occasionally, the radiologist will use a transvaginal ultrasound when she evaluates a multiple-gestation patient. “Transvaginal ultrasounds may be reported separate or in addition to one of the transabdominal ultrasounds,” says Hembree.

For transvaginal ultrasounds, you should report 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) only once. You can try adding modifier 22 (Increased procedural services) if the documentation indicates significant additional physician work. But your radiologist will normally not use the transvaginal scan for an extensive fetal examination.

Heads up: Remember, all obstetrical ultrasounds are transabdominal except 76817, and your physician may have to do a transvaginal in addition to a transabdominal exam. If your physician performs both types of ultrasounds during the same visit, you can report both by appending modifier 59 to 76817. But keep in mind, you must have separate reports for both approaches. Also, document the ICD-9 codes that support the medical necessity for conducting both abdominal and vaginal examinations.