Ob-Gyn Coding Alert

Question: I have recently read on Codify that it is appropriate to use CPT® code 76801 on a fetus that is over 16 weeks. I might be interpreting this incorrectly, but per the AMA Radiology Coding Strategies book, it says “The OB ultrasound codes are classified according to: the length of gestation. Codes 76801 and 76802 are used for complete exams performed during the first trimester, while 76805 and 76810 are used for complete exams performed during the second and third trimester.” So that means a 16 week gestation would be in the second trimester, so I still don’t understand how we can use 76801.

Also, the American College of Radiology states “When the pregnancy is in the first trimester (less than 14 weeks), the coder should remember that the required elements for CPT® code 76801 will be those that are ‘appropriate for gestation’ and ‘visible.’ 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. If any of the elements are not documented, the limited OB ultrasound study should be assigned (76815).” So I am a little confused on how we can use 76801 on a fetus older than 14 weeks when all the material I have read points out the gestation on these codes. This is the first time I am hearing that if all elements for the 76805 were not documented, that we would use 76801 when gestation age is greater than 14 weeks, as the code states. Can you help?

Codify Subscriber

Answer: These ultrasound codes were divided by age, because it is unrealistic to expect a lot to be seen at less than 14 weeks gestation. The 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) code reflects less work by the ob-gyn, but because all of the ultrasound codes describe the required physical elements for reporting them, that information is more important than the age of the fetus.

Watch out: Auditors occasionally see an ultrasound report that lists all of the requirements that were not visualized and but with no explanation of why they were not. Simply spitting out a report that has a ‘not visualized’ area is not sufficient to meet the criteria in CPT® for billing ultrasounds.

In addition, CPT® indicates that if all of the elements of a complete ultrasound are not documented, you should report a limited ultrasound code for that category. Remember, 76801 and 76805 (… after first trimester [> or = 14 weeks 0 days] …) do not represent “complete” ultrasounds in that vein. They represent the expected work for a fetalevaluation. Therefore, if the ob-gyn does not document allof the elements for 76805 and does not document why allof the elements where not performed or visualized, then youhave not met the requirements for billing 76805. Instead,you either go down one level (76801), which usually includes all of the elements that were performed, or you go with 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], 1 or more fetuses) if the ob-gyn only did one or more of the elements listed for that code.

Bottom line: You will have to eventually explain to a payer why you billed a level of ultrasound when the work requirements for it were not met (oh, and then why you are billing them again for a follow-up to complete the examination you did not complete but for which you were paid in full).