Deliver Coding Expertise for Maternal-fetal Medicine Specialist Services
Complicated pregnancies require optimal care with greater time and risk.
By Pamela K. Kostantenaco, LPN, CPC, CMC
Maternal-fetal medicine specialists’ practices receive patients by referral, most prominently from obstetricians and gynecologists (OB/GYNs). Patients are generally limited to those with high-risk pregnancies and whose care requires advanced expertise and greater time and risk. Let’s review the ultrasound studies commonly performed by these specialists.
Scanning for Fetal Problems
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 is not a routine scan; it is for a known or suspected fetal anatomic or genetic abnormality (i.e., previous anomalous fetus, abnormal scan this pregnancy, etc.). The performance of 76811 would be rare outside of referral practices with special expertise in the identification of, and counseling about, fetal anomalies.
Code 76811 describes the extensive fetal examinations that have become possible over the last decade, known as “level II,” “targeted,” “comprehensive,” or “genetic” scans. Some clinical indications that complicate pregnancy to perform this study are:
- Infection and viral diseases
- Diabetes mellitus
- Drug dependence
- Congenital cardiovascular disorders
- Twin pregnancy with or without fetal loss and retention of one fetus
- Triplet pregnancy with or without fetal loss and retention of one or more fetus
- Quadruplet pregnancy with or without fetal loss and retention of one or more fetus(es)
- Hydrocephalic fetus causing disproportion
- Other fetal abnormality causing disproportion,
- Central nervous system malformation in fetus
- Chromosomal abnormality in fetus
- Hereditary disease in family possibly affecting fetus
- Suspected damage to fetus from viral disease in the mother
- Suspected damage to fetus from other disease in the mother
- Suspected damage to fetus from drugs
- Suspected damage to fetus from radiation
- Other known or suspected fetal abnormality
- Unspecified known or suspected fetal abnormality affecting management of mother
- Rhesus isoimmunization
- Isoimmunization from other and unspecified blood-group incompatibility
- Poor fetal growth
- Elderly primigravida
- Elderly multigravida
- Abnormality in fetal heart rate or rhythm, Umbilical cord complications
- Some payers are considering adding the following as new indications for this study:
- Obesity complicating pregnancy, childbirth, or the puerperium,
- Pregnancy resulting from assisted reproductive technology
Now that we understand some clinical indications for this study, let’s discuss the depth of the maternal and fetal anatomical evaluations. Components considered integral to 76811 are marked with an asterisk (*).
Evaluation of Intracranial, Facial, and Spinal Anatomy:
- Lateral ventricles*, third and fourth ventricles
- Cerebellum*, integrity of lobes*, vermis*
- Cavum septum pellucidum
- Cisterna magna measurement*
- Nuchal thickness measurement (15-20 weeks)*
- Integrity of cranial vault
- Examination of brain parenchyma, (e.g., for calcifications)
- Ear position, size
- Upper lip integrity*
- Mandible size
- Facial profile*
- Orbital sizes and separation (e.g., hypertelorism, hypotelorism)
Evaluation of the Chest:
- Presence of masses*
- Pleural effusion*
- Integrity of both sides of the diaphragm*
- Appearance of lung parenchyma*
- Appearance of ribs
Evaluation of the Heart:
- Cardiac location and axis*
- Outflow tracts*
Evaluation of the Abdomen:
- Bowel echogenicity*
- Adrenal glands
Evaluation of Genitalia:
- Gender (whether parents wish to know the sex of child)
Evaluation of Limbs:
- Number, size, and architecture*
- Anatomy and position of hands*
- Anatomy and position of feet*
Evaluation of the Placenta and Cord:
- Placental cord insertion site*
- Placental masses*
- Umbilical cord (number of arteries)
Evaluation of Amniotic Fluid:
- Semi-quantitative evaluation (amniotic fluid index) when appropriate
Evaluation of the maternal anatomy is a required component for this study. If the ovaries are not visualized, etc., there must be a notation in the ultrasound report to reflect this (e.g., “ovaries non-visualized due to late gestation”).
Nuchal Translucency Screening
Nuchal translucency screening (76813 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation) must be done between weeks 11 and 14; an accurate date of conception is important for an accurate result. (A recent study found that nuchal translucency scans done during week 11 were the most accurate because the fold is most translucent then.)
Nuchal translucency screening can be combined with blood tests for more definitive results. For example, the first trimester blood test measures the free human chorionic gonadotropin (beta-hCG) hormone, pregnancy associated plasma protein A (PAPP-A). Low levels of PAPP-A early in pregnancy indicate increased risk of genetic abnormalities, heart problems, and preterm birth. The results of these two blood tests plus the nuchal translucency screening, known as the first trimester combined screening, can be combined into one number that represents the likelihood of a genetic abnormality.
Required components of the procedure are:
- Fetal viability
- Crown-rump measurement
- Nuchal thickness measurement
Example: The ultrasound transducer is oriented until a mid-sagittal view of the embryo is obtained. The embryo is observed at high magnification until the embryonic neck is in a neutral position and spontaneous embryonic movement allows for differentiation between the outer edge of nuchal skin and the amnion. At least three separate measurements of the distance between the inner edges of the nuchal translucency are performed. The largest measurement from an acceptable image is compared to crown-rump length and gestational age-specific medians. A new risk of Down’s syndrome (trisomy 21) is calculated.
Doppler Umbilical Scanning
There are very few clinical indications to perform 76820 Doppler velocimetry, fetal; umbilical artery. Umbilical artery Doppler velocimetry is considered medically necessary in pregnancies complicated by intra-uterine growth restriction, oligohydramnios, twin-to-twin transfusion syndrome (TTTS), and/or discordant fetuses. Discordant fetal growth is common in multiple gestation, and usually is defined by a 15-25 percent reduction in the estimated fetal weight of the smaller fetus when compared with the largest. When used in this setting, accepted guidelines indicate that decisions regarding timing of delivery should be made using a combination of information from the Doppler ultrasonography and other tests for fetal well being, along with careful monitoring of maternal status.
Example: The physician reviews the prenatal records and reviews previous ultrasound reports and/or films. Next, a visualization is obtained of a segment of the umbilical cord, and a duplex Doppler sampling gate (the amount of sample volume) is placed over a portion of an umbilical artery most perpendicular to the axis of the gate. Gain and filters are adjusted to ensure adequate recording of diastolic flow. Two to four waveforms are recorded during the period when fetus is inactive and fetal breathing is absent. Electronic calipers are used to measure peak systolic and end diastolic frequency shift. One of several commonly used indices is then calculated.
The results of two to four waveforms are averaged, and comparison of specific normal values to gestational age is made.
Doppler Cerebral Artery Scanning
Middle cerebral artery (MCA) Doppler velocimetry (76821 Doppler velocimetry, fetal; middle cerebral artery) is considered medically necessary for pregnancy complicated by either TTTS or suspected fetal anemia in conditions such as isoimmunization and parvovirus B-19 infection.
A variety of fetal and maternal blood vessels are evaluated by Doppler wave form analysis to assess the risk of adverse perinatal outcome. The most commonly interrogated vessels are the umbilical arteries. Umbilical artery Doppler flow velocimetry has been adapted for use as a technique of fetal surveillance, based on the observation that flow velocity waveforms in the umbilical artery of normally growing fetuses differ from those of growth-restricted fetuses. Abnormal flow velocity waveforms are correlated histopathologically with small-artery obliteration in placental tertiary villi and functionally with fetal hypoxia and acidosis, as well as with perinatal morbidity and mortality.
Example: The physician reviews the prenatal records and the previous ultrasound reports and/or films. A real-time ultrasound is performed to locate the fetal head. The anterior wing of the sphenoid bone is identified, as well. Color Flow Doppler is used to image the circle of Willis. A pulsed Doppler gate is placed over the middle cerebral artery near its origin from the circle of Willis, and transducer probe orientation or gate orientation is adjusted to ensure angle of insonance is close to zero degrees. Two to four measurements are then obtained and the highest velocity is recorded. A comparison of peak systolic velocity is performed to published gestational age-specific norms. The patient is informed of the results. The results are then communicated, and recommendations made to the referring physician. The written report is then prepared and signed.
Fetal echocardiogram 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording is a detailed evaluation of cardiac structure and function. This is independent of the detailed fetal anatomical evaluation previously described by 76811 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation. Fetal echocardiography typically involves a sequential, segmental analysis of three basic areas (atria, ventricles, and great arteries and their connections).
The following cardiac images should be obtained during 76825:
- Four-chamber view
- Left ventricular outflow tract
- Right ventricular outflow tract
- Three-vessel and trachea view
- Short-axis views (“low” for ventricles and “high” for outflow tracts)
- Aortic arch
- Ductal arch
- Superior vena cava
- Inferior vena cava
Maternal indications for 76825 include:
- Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)
- Familial inherited disorders (e.g., Marfan syndrome)
- First-degree relative with congenital heart disease
- In-vitro fertilization
- Metabolic disease (e.g., diabetes mellitus and phenylketonuria)
- Teratogen exposure (e.g., retinoids and lithium)
Fetal indications include:
- Abnormal cardiac screening examination
- Abnormal heart rate or rhythm
- Fetal chromosomal anomaly
- Extracardiac anomaly
- Increased nuchal translucency
- Monochorionic twins
- Unexplained severe polyhydramnios
Maternal-fetal Medicine Specialists
Maternal-fetal medicine specialists, also known as “perinatologists” or “high-risk OBs,” are OB/GYNs who receive two to three years of additional training, education, and practice experience to gain special competencies in various obstetrical, medical, and surgical complications of pregnancy. These competencies include:
- Intensive care in the area of complicated pregnancies
- Obstetrical ultrasound
- All of the procedures used in the field of maternal-fetal medicine such asfetal surgery, complex ultrasound studies, percutaneous umbilical blood sampling, fetal intravascular transfusions, genetic procedures, etc.
The maternal-fetal medicine specialist provides education and research concerning the most recent approaches and treatments for obstetrical problems. The maternal-fetal medicine specialist promotes and delivers the most optimal care for these complicated pregnancies.
Maternal-fetal medicine specialists are complementary to OBs in providing consultations, co-management, or direct care for complicated patients, both before (pre-conceptual counseling) and during pregnancy. The relationship between the obstetrician and the maternal-fetal specialist will depend on the acuity of the condition and local circumstance.
This procedure, 76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete, can be reported with 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording when the clinical indications exist. Spectral, continuous wave, color, and/or power Doppler sonography can be used to evaluate the following structures for potential flow or rhythm disturbances:
- Pulmonary veins
- Foramen ovale
- Atrioventricular valves
- Atrial and ventricular septa
- Aortic and pulmonary valves
- Ductus arteriosus
- Aortic arch
After any ultrasound study, post-service work includes:
- Preparing a comprehensive report for the medical record
- Discussing the findings with the patient and referring physician when appropriate
- Reviewing and signing the prepared report
Conveying normal ultrasound results to the patient is a component of the ultrasound charge. Counseling or any further discussion with the patient (if there are abnormal findings) and developing management/treatment plan options, are not considered a component of the ultrasound report, and can be reported separately with the appropriate evaluation and management (E/M) code.
Example: Patient is sent for an ultrasound procedure. During the study, you identify a fetal cardiac anomaly. A discussion takes place with the patient and/or family members, explaining the cardiac anomaly, further radiological studies (fetal echocardiography, Doppler, etc.), recommendations to seek another professional opinion from a pediatric cardiologist, possible surgical options, etc. This type of discussion would not be considered a component of the ultrasound, and can be reported separately with the appropriate E/M code. Some payers may require you to attach modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service to the E/M code.
Pamela K. Kostantenaco, LPN, CPC, CMC, is president of PKK Consulting and lead coder for the Society for Maternal-Fetal Medicine (SMFM) Coding Committee since its inception in 2001. She has been instrumental in developing coding resource materials and has been keynote speaker for coding courses by SMFM. She has more than 25 years of coding-related experience, specializing in providing consultative services to clients in the OB and maternal-fetal medicine fields.