Gather Components for OB Ultrasound Codes 76805 and 76811

Gather Components for OB Ultrasound Codes 76805 and 76811

By Pamela K. Kostantenaco, LPN, CPC, CMC,

Knowing the differences between these codes will clear up billing confusion.

There has been ongoing confusion among coders, auditors, ultrasonographers, and physicians regarding the difference between CPT® codes 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) and 76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation.

The most common question is, “When can I report 76811?”

76811 Is a Specialty Code

The service described by 76811 is not intended to be the routine scan performed for all pregnancies. Rather, it’s intended for a known or suspected fetal anatomic, genetic abnormality (e.g., previous anomalous fetus, abnormal scan this pregnancy, etc.), or increased risk for fetal abnormality (e.g., advanced maternal age, diabetes, fetus at risk due to teratogen or genetics, abnormal prenatal screen). Performing this service is rare outside of referral practices with special expertise in fetal anomaly detection and counseling.

The American Institute of Ultrasound in Medicine (AIUM) and the Society for Maternal Fetal Medicine (SMFM) hosted a meeting to develop the appropriate indications for performing a detailed fetal anatomic ultrasound examination, the components of the examination, and the training required to interpret it (see Consensus Report on the Detailed Fetal Anatomic Ultrasound Examination: Indications, Components, and Qualifications for more information). The participants included representatives from the AIUM, SMFM, the American College of Obstetricians and Gynecologists, the American College of Osteopathic Obstetricians and Gynecologists, the American College of Radiology, the Society of Diagnostic Medical Sonography, and the Society of Radiologists in Ultrasound.

To answer fully our earlier question, let’s address the required components for reporting 76805 and 76811, as well as common indications for 76811 based on the census report.

Required Components for 76805

The study described by 76805 is commonly performed as a “routine screening ultrasound” at approximately 16-20 weeks gestation on a low-risk pregnancy.

Head and neck:

  • Lateral cerebral ventricles
  • Choroid plexus
  • Midline falx
  • Cavum septi pellucidi
  • Cerebellum
  • Cisterna magna

Face:

  • Upper lip

Chest: 

  • Cardiac activity
  • Four chamber view
  • Left ventricular outflow tract
  • Right ventricular outflow tract

Abdomen:

  • Stomach (presence, size, and situs)
  • Kidneys
  • Urinary bladder
  • Cord insertion site into fetal abdomen
  • Umbilical cord vessel number

Spine:

  • Cervical
  • Thoracic
  • Lumbar
  • Sacral spine

Extremities:

  • Legs
  • Arms

Placenta: 

  • Placenta location
  • Relationship to internal os
  • Appearance
  • Placental cord insertion (when possible)

Standard evaluation:

  • Fetal number
  • Presentation
  • Qualitative or semi-qualitative estimate of amniotic fluid

Biometry:

  • BPD
  • Head circumference
  • Femur length
  • Abdominal circumference
  • Fetal weight estimate

Maternal anatomy:

  • Cervix (transvaginal when indicated)
  • Uterus
  • Adnexa

Required Components for 76811

CPT® code 76811 requires all of the components of 76805, plus the following. Some components depend on the gestational age at the time the examination is performed. Components marked with an asterisk (*) are performed when medically indicated.

Head and neck: 

  • Third ventricle and fourth ventricle*
  • Corpus callosum*
  • Integrity and shape of cranial vault
  • Brain parenchyma
  • Neck

Face: 

  • Profile
  • Coronal face (nose/lips/lens*)
  • Palate* maxilla, mandible, and tongue*
  • Ear position and size*
  • Orbits*

Chest: 

  • Aortic arch
  • Superior vena cava/Inferior vena cava
  • Three vessel and trachea view
  • Lungs
  • Integrity of diaphragm
  • Ribs*

Abdomen: 

  • Bowel – small and large*
  • Adrenal glands*
  • Gallbladder*
  • Liver
  • Renal arteries*
  • Spleen*

Spine: 

  • Shape and curvature

Extremities:

  • Number: Architecture and position
  • Hands
  • Feet
  • Digits: Number and position*

Placenta:

  • Masses
  • Placental cord insertion
  • Accessory/Succenturiate lobe with location of connecting vascular supply to primary placenta*

Biometry:

  • Cerebellum*
  • Inner and outer orbital diameters*
  • Nuchal thickness (16-20 weeks)
  • Nasal bone measurement (15-22 weeks)
  • Humerus*
  • Ulna/Radius*
  • Tibia/Fibula*

Note: If any of the required fetal or maternal components are non-visualized due to fetal position, late gestational age, maternal habitus, etc., the circumstance must be clearly noted in the ultrasound report to meet the requirements for billing this service.

Common Indications for 76811

Indications for a detailed fetal anatomic examination include:

  • Previous fetus or child with a congenital, genetic, or chromosomal abnormality
  • Known or suspected fetal anomaly or known growth disorder in the current pregnancy
  • Fetus at increased risk for congenital anomaly, such as:
  • Maternal pregestational diabetes or gestational diabetes diagnosed before 24 weeks gestation
  • Pregnancy conceived via assisted reproductive technology
  • Maternal BMI > or = 35 kg/m2
  • Multiple gestation
  • Abnormal maternal serum analytes including alpha fetoprotein level and unconjugated estriol
  • Teratogen exposure
  • First trimester nuchal translucency measurement > or = 3.0 mm
  • Fetus at increased risk for genetic or chromosomal abnormality, such as:
  • Parental carrier of chromosomal or genetic abnormality
  • Maternal age > or = 35 years at delivery
  • Positive screening test for aneuploidy, including NIPT
  • Soft aneuploidy marker noted on ultrasound
  • First trimester nuchal translucency > or = 3.0mm
  • Other conditions affecting the fetus, including:
  • Congenital infections
  • Maternal drug dependence
  • Isoimmunization
  • Oligohydramnios
  • Polyhydramnios

Example of 76805

The patient is 25-years-old, G2 P1, with a menstrual age of 18 weeks. An obstetrical ultrasound is ordered for routine anatomical evaluation and confirmation of dates. There is no family or personal history of a fetal or maternal condition. The patient’s generalist obstetrician (OB) does not anticipate any problems because the pregnancy has been uneventful, thus far. A complete transabdominal ultrasound is performed. All required maternal and fetal components previous (as noted, above) are assessed and found to be normal.

The correct coding in this example is 76805 with V28.3 Encounter for routine screening for malformation using ultrasonics.

Example of 76811

A 41-year-old, pregnant patient is referred from the generalist OB to the maternal-fetal medicine specialists for an obstetrical ultrasound at 18 weeks gestation. Her obstetric history is significant for an intrauterine demise (IUFD) at 25 weeks gestation, a fetus with a skeletal defect (short rib and polydactyly) who died shortly after birth, one full-term delivery (live, no complications), and two early miscarriages.

In addition to her poor obstetrical history, she has abnormal lab results that show an increased risk for Down syndrome of 1:30. She would like to avoid invasive testing (i.e., amniocentesis), and requests a comprehensive fetal anatomical survey to determine whether the fetus has a recurrence of a skeletal dysplasia or markers for Down syndrome. A detailed transabdominal ultrasound is performed. All required maternal and fetal components are assessed. Based on the limitations of the study, there does not appear to be any structural fetal anomalies.

The correct coding in this example is 76811 with:

659.63 Elderly multigravida, antepartum condition or complication

655.83 Other known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, antepartum condition or complication

655.13 Chromosomal abnormality in fetus, affecting management of mother, antepartum condition or complication

V89.03 Suspected fetal anomaly not found

These examples are provided to assist clinicians and coders, and are not intended to be all-inclusive. Payer requirements vary. Contact your local payers for specific listings of clinically indicated diagnoses that warrant a detailed ultrasound (76811).


 

Pamela K. Kostantenaco, LPN, CPC, CMC, is president of PKK Consulting and was the lead coder for the Society for Maternal-Fetal Medicine (SMFM) Coding Committee since its inception in 2001 and continues to provide consultative services to the committee. She has been instrumental in developing coding resource materials for SMFM, and continues to be the keynote speaker for the SMFM coding courses. Kostantenaco has over 25 years of coding-related experience, and specializes in providing consultative services to clients in the obstetrics and maternal-fetal medicine fields. She is a member of the Lakeland, Florida, local chapter.

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Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
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Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

5 Responses to “Gather Components for OB Ultrasound Codes 76805 and 76811”

  1. Deborah says:

    What code would be appropriate for billing an ultrasound for suspected or confirmed Zika virus?
    Is there a limit to the number of times 76811 can be billed?

  2. William B. Blessed says:

    My office is an MFM practice which does a large number of 76811 exams. We have a question regarding how to code an ultrasound exam that is incomplete. For example, an OB may order a fetal ultrasound at 16 – 18 weeks on a patient with diabetes. Very often, we cannot see all of the components necessary for a 76811 exam due to early gestational age,/maternal body habitus/etc and recommend a follow-up exam at 19-20 weeks.
    Should the initial exam still be coded 76811 with the followup exam coded as 76816?

  3. ASaiz says:

    You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  4. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

  5. ASaiz says:

    Thank you for your comment. You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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