Use This Practical Guide to Confidently Code Obstetric Ultrasounds
Learn the difference between a standard complete exam and a detailed fetal anatomic exam. Obstetric ultrasound coding can feel deceptively simple at first glance. After all, the exam headers often look the same, and the gestational age might only differ by a few days. But as you already know, the difference between correct coding and an audit risk often comes down to understanding what was actually visualized, why the exam was performed, and whether the documentation truly supports the code. Learn how to code obstetric ultrasounds accurately and see how to avoid some common coding traps. Start With the Basics: First Trimester Versus 14 Weeks and Beyond If the pregnancy is less than 14 weeks 0 days and the exam is transabdominal, you’re looking at code 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) for the first or only gestation. If more than one fetus is documented, you’ll add +76802 (… each additional gestation (List separately in addition to code for primary procedure)) for each additional gestation. To report 76801 (and +76802), the documentation must show that the provider evaluated or documented a reason for nonvisualization of all required elements, including: If even one of these elements is missing without explanation, you should pause and query the ob-gyn before assigning the code. Once the pregnancy reaches 14 weeks 0 days or later, your baseline complete exam code becomes 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) for the first or only gestation, with +76810 (… each additional gestation (List separately in addition to code for primary procedure)) for each additional fetus. For 76805, the documentation must include evaluation (or a documented reason for nonvisualization) of the following elements: If these elements are present, 76805 is appropriate. If not, you need to consider whether the exam was limited or focused instead. Understand When a Detailed Exam Is Truly Detailed One of the most important distinctions you’ll make is between a standard complete exam (76805) and a detailed fetal anatomic exam (76811 [Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation]). Code 76811 isn’t a routine scan. The procedure is intended for pregnancies with suspected or confirmed abnormalities or other high-risk indications and is typically performed by providers with specialized expertise. You should never assume a detailed exam was performed just because the report is lengthy or uses impressive terminology. To report 76811, the provider must document all required elements of 76805 plus a detailed anatomic evaluation that includes, when clinically indicated: If any element isn’t visualized, the report must clearly state why. If that level of detail isn’t present, you shouldn’t code 76811, even if the exam header says “detailed ultrasound.” A common and correct workflow is to report 76805 at the initial anatomy scan, then report 76811 at a subsequent visit when a suspected anomaly requires further evaluation. Don’t Overuse the ‘Quick Look’ Code 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) represents a limited obstetrical ultrasound. Think of this as a targeted, problem-focused look rather than a full evaluation. It may include one or more of the following: You’ll typically see 76815 when a provider is checking something specific or revisiting an issue that was difficult to visualize earlier. Importantly, 76815 is reported once per study, not per fetus, regardless of how many fetuses are present. Watch out: This is where many coders stumble. If the purpose of the exam is to reassess fetal growth or reevaluate a previously identified abnormality, 76815 is incorrect. Follow-Up Does Not Always Mean Limited: Using 76816 Correctly You’ll use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus) for follow-up obstetrical ultrasounds that reassess fetal size, interval growth, or previously identified or suspected abnormalities. This is a focused follow-up exam, but it’s more involved than a quick look. Key points to remember about 76816: Always review the patient’s ultrasound history. If there has been no prior complete fetal and maternal evaluation, and the current exam meets all criteria for a complete study, you should code the complete exam instead. Put It All Together With a Real-World Example Scenario: A patient presents to the emergency department with vaginal bleeding early in pregnancy. A transvaginal obstetrical ultrasound is performed, and the provider documents two subchorionic hematomas at 8 weeks and 3 days. In this setting, the correct code is 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) for the transvaginal obstetrical ultrasound. Codes such as 76801 don’t apply here because that code represents a planned, complete first-trimester evaluation using a transabdominal approach. One week later, the patient returns for a planned first-trimester fetal and maternal evaluation. The indication includes dating and a follow-up exam of the hematomas. If the documentation supports all required elements, you may report 76801. The presence of the term “follow-up” doesn’t automatically push you to 76816. At a subsequent visit, the provider performs another ultrasound specifically to reassess the subchorionic hematomas. This time, the purpose of the exam truly is reevaluation of a previously identified condition. Assuming appropriate documentation, 76816 is now the correct code. Final Tips for Coding Obstetric Ultrasounds Accurately When you’re coding obstetric ultrasounds, always slow down and focus on three things: Never code based solely on the exam title, and don’t let the term “follow-up” steer you without context. When in doubt, query the provider. Clear documentation protects both you and the practice, and it ensures that the ultrasound services are coded exactly as CPT® intends. With careful review and a structured approach, you can code obstetric ultrasounds confidently and compliantly every time. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
