Advanced Search

Ob-Gyn Coding Alert

You Be the Coder:

Check Your US Diagnoses Against This Advice

Published on Sat Jun 26, 2010

Question:

The ob-gyn routinely performs an ultrasound (US) at 7-9 weeks (76801) to check the number of fetal sacs as well as checking for fetal heart tones. Is this diagnosis V28.3? 

She also routinely performs an US (76815) for a single pregnancy at 28 weeks to check if fetal growth matches estimate date of confinement (EDC). The diagnosis I would use for that is V28.81. Is that correct? 

California Subscriber

Answer:

For that first exam at 7-9 weeks, you can use V28.3 (Encounter for routine screening for malformation using ultrasonics). But code V28.81 (Encounter for fetal anatomic survey) is for a fetal anatomic survey and is more appropriate to report with 76805/+76810 (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).

Correct options: You have a gamut of diagnoses to support the ultrasound at 28 weeks, all of which should reflect the reason for the ultrasound. For instance:

If your ob suspects size/date discrepancy but rules it out, you can report V89.04 (Suspected problem with fetal growth not found).

To check for size/date discrepancy that the ob-gyn does not rule out, the code is 649.63 (Uterine size date discrepancy; antepartum condition or complication).

If the fetus appears larger or smaller than normal in relation to the EDC, then 656.53 (Poor fetal growth, affecting management of mother; antepartum condition or complication) or 656.63 (Excessive fetal growth affecting management of mother antepartum) are the correct options.

If the ob-gyn is performing this US as a screening in the absence of any other medical indication and a complete anatomic survey was documented, you can report V28.81 (Encounter for fetal anatomic survey).

Watch out: Code 76815 (Ultrasound, pregnant uterus, real time with image documentation, limited [e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) is a limited exam that an ob-gyn performs to answer an immediate clinical problem, rather than follow-up for a continuing situation. When an ob-gyn performs a limited exam, diagnoses must support this service, diagnoses which indicate those problems such as non-reassuring fetal heart rate, oligo- or polyhydramnios, or abnormal position of the fetus.

Remember: You would report fetal growth measurements after a complete ultrasound as 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [e.g., 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).

ICD-10: When ICD-9 becomes ICD-10 in 2013, you'll report the following equivalents:

V28.81and V28.3 = Z36 (Encounter for antenatal screening of mother). Note that in ICD-10, you do not differentiate the reason for the screening the way you do in ICD-9.

649.63 = O26.84X (Uterine size-date discrepancy complicating pregnancy)

656.53 = O36.59X0 (Maternal care for other known or suspected poor fetal growth)

656.63 = O36.6Xx0 (Maternal care for excessive fetal growth)

V89.04 = Z03.74 (Encounter for suspected problem with fetal growth ruled out).

Note: A lower case x means you report that as part of the code; an upper case X means you will add an applicable number.

Other Articles in this issue of

Ob-Gyn Coding Alert

View All