Ob-Gyn Coding Alert

Reader Questions:

For Follicle Check, Report This Code

Question: The patient sees primary OB to check on her follicles, as she is trying to conceive naturally. The ob-gyn performs transvaginal ultrasound. Is the correct CPT® code 76830 or 76857? Also, which ICD-10-CM code should I use?

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Answer: The descriptors for 76830 (Ultrasound, transvaginal) and 76857 (Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)) should clearly lead you to the correct code, as you state the procedure is a “transvaginal ultrasound.”

Regarding the ICD-10-CM, you would code whatever reason the specific patient is having the scan, or findings of the scan. Possible examples include N83.11 (Corpus luteum cyst of right ovary), N97.1 (Female infertility of tubal origin), R10.2 (Pelvic and perineal pain), or Z31.69 (Encounter for other general counseling and advice on procreation).

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