Radiology Coding Alert
No Pregnancy = No OB Ultrasound?
Question: For an ultrasound, the radiologist documented measurements of the uterus, endometrial complex, and ovaries. She noted no evidence of intrauterine pregnancy, no free fluid in the cul-de-sac, physiologic follicle formation, and positive Doppler flow in the ovaries. The patient had syncope but no confirmed pregnancy. Should I report an obstetric or nonobstetric ultrasound? Michigan Subscriber Answer: Because the patient has no confirmed pregnancy before the ultrasound, you should report a nonobstetric ultrasound. The AMA's CPT Assistant (October 2001) states that when a female patient presents with no confirmed pregnancy, you should report a nonobstetric ultrasound, regardless of whether the ultrasound confirms pregnancy. On the flip side, if the patient had a confirmed pregnancy and presented for an ultrasound that might be pregnancy related, but the ultrasound does not demonstrate a pregnancy, you would report an obstetric ultrasound code. ICD-9: Because you don't have a confirmed diagnosis, you should report the symptom that led to the ultrasound: 780.2 (Syncope and collapse).
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