Radiology Coding Alert

Question: You are working on a report of a fetal transabdominal ultrasound with a gestational age of 19 weeks. The dictation documents one gestational sac, a full review of intracranial/spinal/abdominal anatomy, a four-chambered heart, and placental location. Your colleague suggests that you use code 76805. Is this correct?

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The answers for You Be the Coder and Reader Questions were reviewed by Michele Midkiff, CPC-I, RCC, an interventional and neuro-interventional radiology coding consultant in Mountain View, California.

Answer: Obstetrical coding is one of the most challenging areas of diagnostic radiology coding. From a procedural perspective, a firm grasp on both anatomy and procedural guidelines is crucial in order to reach the correct CPT^® code(s).  

The question at hand requires us to compare and contrast two fetal ultrasound codes:

• 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 firstgestation
• 76815, Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heartbeat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or morefetuses

To justify the use of code 76805, you have to meet a set of very stringent criteria documenting numerous anatomical variants within the fetus and its surrounding parts. CPT^® guidelines state that each of the following must be documented in order to apply code 76805:

• Determination of 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,
• 4 chambered heart,
• Umbilical cord insertion site,
• Placenta location and amniotic fluid assessment, and
• Examination of maternal adnexa (when visible).

It’s clear that the anatomical sites referenced in the question at hand do not meet the criteria for the use of code 76805. The referenced report is missing documentation of amniotic fluid assessment, the umbilical cord insertion site, and the maternal adnexa. While the adnexa are not a necessary component depending on visibility, it is important for the provider to, at the very least, document the degree of visualization on the ultrasound.

Based on the anatomical sites documented in the question, the coder should opt for the limited fetal ultrasound code 76815. CPT^® refers to this code as a “quick look” procedure — only requiring one of the following anatomical sites to be documented:

• Fetal heartbeat,
• Placental location, or
• Fetal position and/or qualitative amniotic fluid volume.

Some coders might initially feel overwhelmed by the need to document each of the aforementioned anatomical variants in order to reach code 76805. While this is not always the case, radiologists tend to utilize obstetric-specific templates as a reminder to check for each of the required criteria. Subsequently, these templates also benefit the coders as it saves them from having to scour the body of a report to check off each required measure.