Radiology Coding Alert

Question: Recently, we performed a limited obstetrical ultrasound transvaginally. I am not sure if this should be coded with CPT 76815 (echography, pregnant uterus, B-scan and/or real time with image documentation; limited [fetal size, heart beat, placental location, fetal position, or emergency in delivery room]) or 76830 (echography, transvaginal).

Anonymous California Subscriber

Answer: This is one of those instances where either code may technically may be correct76830 better describes the transvaginal approach (although it doesnt differentiate between a limited or complete exam), while 76815 more accurately describes the limited scope of the exam.

However, since the medical report most likely documents only impressions from a fetal evaluation, it would be best to assign CPT 76815. Although 76830 could be assigned with a -52 modifier (reduced services), reimbursement may not be as advantageous. For this reason, 76815 is recommended.

Note: Keep in mind, however, that if the report comments on both the fetal and maternal evaluation, CPT 76830 would be appropriately assigned.