Following These Ultrasound Guidelines Means You’re Going the Extra Mile
Master obstetrical ultrasound coding with tips on accurate reporting for codes 76805, 76811, 76815, and 76816 to ensure precise billing and compliance.
OB/GYN Medical Billing & Coding Alert
Test your expertise with a difficult two-part example.
Building on the article from Ob-Gyn Coding Alert (Volume 26, Issue 4) titled "Obstetrical Ultrasound Coding: Mastering Anatomy," it's time to delve deeper into the complex and precise field of obstetrical ultrasound (US) coding.
Are you familiar with how to accurately report more comprehensive fetal anatomical assessments and brief evaluations? Continue reading to learn more.
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Identifying Additional Elements for Reporting 76811
When coding second and third-trimester fetal and maternal evaluation ultrasounds, it's important to distinguish between routine ultrasounds and more detailed assessments.
Understanding the differences between codes 76811 and 76805 is key. Code 76811 (Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires additional documentation beyond the elements for 76805 (Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, after the first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation).
To meet the requirements for 76811, the provider must also document:
- A detailed anatomic evaluation of the fetal brain ventricles;
- Examination of the face, heart/outflow tracts, and chest anatomy;
- Assessment of abdominal organ-specific anatomy;
- Evaluation of the number, length, and architecture of limbs, as well as a thorough review of the umbilical cord, placenta, and other fetal anatomy as clinically indicated.
It's essential to remember that these elements may appear under the same exam header, which is why a careful review of the ob-gyn’s documentation is critical for distinguishing between 76805 and 76811. However, in most cases, the ob-gyn won’t need to perform a more extensive evaluation than what's required for 76805.
The Society for Maternal-Fetal Medicine (SMFM) advises that 76811 should never be a routine scan. It should be performed only by specialists with expertise in the assessment, counseling, or management of fetal anomalies. To report 76811 accurately, the provider must document all required elements, and if any element is missing, the dictation report should include an explanation for the non-visualization.
Know When to Report a Quick Look Exam
Many coders struggle with understanding the limited obstetrical examination code 76815 (Ultrasound, pregnant uterus, real-time with image documentation, limited [e.g., fetal heartbeat, placental location, fetal position, and/or qualitative amniotic fluid volume], 1 or more fetuses).
This code is used when the provider does not document enough elements to meet the criteria for a complete fetal and maternal evaluation. Commonly referred to as a "quick look" exam, it involves one or more of the elements listed in the code description.
According to experts, 76815 is typically used when the physician needs to "go back" and examine something that was obscured or not visible during the complete ultrasound.
However, 76816 (Ultrasound, pregnant uterus, real-time with image documentation, follow-up [e.g., re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ systems suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus) may be the more appropriate code in some cases.
The American College of Radiology (ACR) offers additional guidance
“It is important to note that 76815 includes 'one or more fetuses' in its description and should not be coded more than once per study or fetus. If a study is conducted to reassess fetal size or reevaluate any fetal organ-system abnormality noted on a previous ultrasound, 76816 is the correct code.”
As the ACR highlights, it’s easy to misapply 76815 when the documentation actually requires 76816. Experts recommend using 76816 when physicians suspect an issue and need to investigate that specific concern further.
76816 can be tricky, but there are keynotes in the CPT manual that can help:
“Code 76816 describes an examination to reassess fetal size and interval growth or to reevaluate one or more anatomic abnormalities of a fetus previously identified on ultrasound. This code should be reported once for each fetus requiring reevaluation, using modifier 59 for each additional fetus after the first.”
Follow Along With This Example
Knowing when to report 76816 starts with evaluating the clinical indication. If the indication specifies "follow-up," it’s crucial to review the patient’s chart history to determine the correct code. Remember that the exam header may appear the same as that of a complete fetal and maternal evaluation, like 76805.
Let’s walk through this example to clear up any confusion:
Initial Emergency Room Visit
Example:
A patient presents to the emergency room (ER) with vaginal bleeding during pregnancy. A transvaginal obstetrical ultrasound is performed, revealing two subchorionic bleeds with a gestational age of eight weeks and three days.
In this case, 76817 (Ultrasound, pregnant uterus, real-time with image documentation, transvaginal) is the appropriate code. 76801, on the other hand, is a planned procedure with additional criteria not included in 76817 and requires a transabdominal approach.
Follow-Up Ultrasound Exam
One week later, the patient returned for a follow-up fetal and maternal ultrasound evaluation. The indication for this exam reads: “Follow-up of subchorionic hematomas.”
Here’s where things can get tricky. Many coders, seeing the term “follow-up” in the indication, might immediately opt for 76816. However, it’s essential to examine the patient’s entire obstetrical history before deciding on the appropriate code.
Evaluating the History and Correct Coding
Upon reviewing the patient’s history, you’ll see that the “follow-up” refers to the original ER visit, not a previous fetal and maternal evaluation exam. Since the current exam meets all the necessary criteria, you would report 76801, not 76816, in this case.
Final Follow-Up Exam
The final follow-up exam is a routine evaluation ordered to monitor subchorionic hematomas and ensure they haven’t progressed. As long as this exam meets the necessary CPT elements for a follow-up, you would report 76816 for this exam.
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