Radiology Coding Alert

Question: Does coding for a transvaginal ultrasound (US) for an intrauterine device (IUD) check require appending modifier 52?

Wisconsin Subscriber

Answer: According to the American College of Radiology’s (ACR’s) Ultrasound Coding User’s Guide, a complete non-OB transvaginal US includes examination of the following:

• Uterus;
• Endometrium;
• Ovaries; and
• Adnexa.

However, if you look closer at other authoritative guidance, you don’t necessarily have to append modifier 52 (Reduced services) to 76830 (Ultrasound, transvaginal), or send the report back to the provider for an addendum, if the provider’s documentation of the adnexa does not include each individual component. Clinical Examples in Radiology (Winter 2016) explains that an evaluation of the adnexa is necessary for 76830 billing, but documentation specifically referencing the fallopian tubes is optional. In order to ensure compliance, you still should confirm that the dictation report properly documents the ovaries.

Coder’s note: Despite the fact that this service is checking for an IUD, you should not confuse this with an obstetrical imaging service such as 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal). You will only code for an obstetrical transvaginal US when the clinical indication involves an obstetrical evaluation. However, the ACR also notes that if the clinical indication for a translabial or transvaginal exam states that a pregnant patient is being examined for “external signs and symptoms,” you will report 76857 (Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)) in place of 76830.