Ob-Gyn Coding Alert

If an element isn’t documented, you should query the physician.

You know obstetric ultrasounds can be challenging because the patient condition, number of gestations, and the patient’s trimester will influence on what ICD-10-CM and CPT^® code(s) you report, but that doesn’t mean it’s impossible.

Check out the necessary anatomical criteria you must meet in order to report fetal and maternal evaluations of the first and subsequent trimesters.

Use ACR, Expert Guidance in Meeting 76801 Criteria

Start out with a look at the criteria you’ll need to meet in order to report codes 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) and +76802 (… each additional gestation (List separately in addition to code for primary procedure)):

• Determination of the number of gestational sacs and fetuses,
• Gestational sac/fetal measurements appropriate for gestation (younger than 14 weeks, 0 days),
• Survey of visible fetal and placental anatomic structure,
• Qualitative assessment of amniotic fluid volume/gestational sac shape, and
• Examination of the maternal uterus and adnexa.

What’s first important to note is that you do not always have to meet each of the above criteria in order to report 76801/+76802. As per American College of Radiology (ACR) guidelines, the required elements for 76801 reporting are those that are “appropriate for gestation” and “visible.” Additionally, the ACR explains that “if any of the elements listed in the CPT^® code book are not able to be measured or are not visible, then the report should document that information in order to assign 76801.”

On the other hand, if the report inadequately documents why one or more of the above criteria is missing, then you should report 76815 in place of 76801.

Coders sometimes have trouble knowing whether there is sufficient documentation in the report to meet the criteria for the assessment of amniotic fluid. The ACR elaborates on this element, explaining that “among the required elements, ‘qualitative assessment of amniotic fluid volume’ refers to the radiologist’s statement, based on his or her experience and knowledge, that the volume is adequate or inadequate.”

“Amniotic fluid is never mentioned on the earliest obstetrical USs of seven or eight weeks,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. In fact, an amniotic fluid assessment doesn’t become relevant until around week 14 or so. Most often, amniotic fluid will be evaluated and documented on the fetal anatomical structural evaluation at around 18 to 20 weeks, Rosenberg explains.

As you can see, an assessment for amniotic fluid is simply not possible for a large portion of the first trimester. When you do not see an amniotic fluid assessment documented in the first trimester, you should refer back to the ACR guideline referencing the reporting of elements that are “appropriate for gestation.” An assessment for amniotic fluid seven weeks into pregnancy, for example, is not yet appropriate to report upon given the gestational time period. Additionally, when providers document “no free fluid” on the seven to eight-week fetal US, they are referring to free fluid within the peritoneal space, not amniotic fluid.

Note Similarities, Differences From 76805 Reporting

Next up, have a look at the criteria you need to meet in order to report 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 +76810 (… each additional gestation (List separately in addition to code for primary procedure)):

• Determination of the 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,
• Four-chambered heart,
• Umbilical cord assessment,
• Examination of maternal adnexa, when visible.

In your provider’s 76805 dictation report templates, you may find a variety of fetal measurement acronyms to keep track of. The use of some of these acronyms and their respective measurements will act as sufficient documentation to check off a given required element. Consider some of the following:

• BPD — Biparietal diameter
• HC – Head circumference
• AC – Abdominal circumference
• FL — Femur length
• OFD — Occipitofrontal diameter
• CI – Cephalic index
• HA ratio — Head to abdomen ratio
• EFW — Estimated fetal weight
• AFI — Amniotic fluid index

With respect to the “survey of intracranial/spinal/abdominal anatomy, the ACR explains exactly what you should be looking for within the report:

• “Mention will need to be made of the head, spine, and abdominal anatomy along with the heart and umbilical cord insertion site. This will be in a ‘survey’ format, and detail may not be provided.”

This means that as long as each respective anatomical component is referenced and documented as “normal” or otherwise, you may consider that portion of the criteria for 76805 accounted for. Usually included in a survey of the intracranial, spinal, and abdominal anatomy is documentation of a four-chambered heart and a three-vessel umbilical cord.

Elaborate on 76805 Elements

Additionally, you will want to make sure there is sufficient documentation of the fetuses’ AFI despite the fact that AFI is not specifically documented as a key element. You should include amniotic fluid measurement in with the second element for 76805, “Measurements appropriate for gestational age (older than or equal to 14 weeks 0 days).” The ACR goes on to outline what you should look out for with respect to amniotic fluid measurements:

• “After the first trimester, the amniotic fluid might be “measured (quantitative), or the report may document this with a qualitative assessment — either is acceptable. If measured, this might also appear in the report simply as an abbreviation and a number.”

Coder’s note: As long as the provider documents a reason as to why an element could not be visualized or measured, you may still report code 76805. If an element is not documented and no reason is given as to why, you should either inquire with the physician as to whether an addendum is needed, or report code 76815 instead of 76805.

“When deciding between sending the report back for an addendum, or down coding to 76815, you must consider a few different variables,” says Lindsay Della Vella, COC, CMCS, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania.

“The first involves how the billing practice is set up. If a third-party billing company is doing the coding, for instance, then there just might not be an option to send back for an addendum. Instead, the client might have guidelines in place instructing the coder what to do if documentation is not met. Other practices might have policy in place that involves the coder sending the report back for an addendum when criteria are not met. There is no right or wrong here, it all depends on the system you have in place,” Della Vella advises.