Radiology Coding Alert

Question: Our practice performed an ordered ultrasound on a patient complaining of pain, and the test revealed that she was pregnant. Should I code an obstetric or nonobstetric ultrasound?

Wisconsin Subscriber

Answer: Because the patient did not have a confirmed pregnancy when she presented for the ultrasound, you should report a nonobstetric ultrasound, such as 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete).

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.

Bonus tip: 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, such as 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).