Radiology Coding Alert

Question: I code for a multi-specialty clinic. An obstetrician ordered a routine ultrasound for a first-time mother at 15 weeks gestation. After finding an anomaly, the radiologist called the obstetrician, who performed an amniocentesis with ultrasonic guidance. How should I code for the ultrasound and guidance the radiologist provided?


Washington Subscriber


Answer: You should report 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 ultrasound. The guidance merits 76946 (Ultrasonic guidance for amniocentesis, imaging supervision and interpretation).

Depending on your payer, you may also need to append modifier 59 (Distinct procedural service) or 51 (Multiple procedures) to 76946 to indicate that the ultrasound and guidance were two different procedures.

Don't forget: If you report ultrasonic guidance and a fetal ultrasound on the same date, your radiologist should include separate reports in the medical record documenting the individual procedures. Your radiologist should also document the specific findings that led to the recommended amniocentesis.