Radiology Coding Alert

Question: I’m filling in for a radiology coder and have a fetal transabdominal ultrasound report. The gestational age is 20 weeks. The documentation lists one gestational sac, fetal heartbeat, position of the fetus, and placental location.

Could you help me identify which CPT^® code to report?

Mississippi Subscriber

Answer: The CPT^® code set includes two fetal ultrasound codes that could apply to your scenario:

• 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)
• 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses)

Both codes require a solid understanding of anatomy and procedural guidelines to report the codes correctly.

To report 76805, the physician must visualize and document criteria according to the CPT^® guidelines. These criteria include:

• 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).

Note: Documentation should support why the physician was unable to view the maternal adnexa. This may occur later in the pregnancy when the baby has grown and is blocking the view of the maternal adnexa.

Based on the information provided in your question, 76805 looks to be the incorrect coding option for the procedure. This is because information regarding the amniotic fluid assessment, umbilical cord insertion site, and the maternal adnexa is missing.

Instead, you’ll assign 76815 to report the transabdominal ultrasound. CPT^® refers to this limited ultrasound as a “quick look” procedure, where the physician needs to document viewing only one of the following:

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

The information you provided matches the documentation requirements for 76815.