Wiki Viability Ultrasound in 2nd Trimester

[jhanmer83]

Hey Everyone,

When a patient comes in for a transabdominal viability/dating ultrasound, but she ends up being in her 2nd trimester between 14 & 18 weeks gestation, how are you coding those? They're basically documenting a 1st trimester viability scan (76801) with maternal and fetal structures, but the patient is a bit further along and it's too soon to do a complete anatomy scan (76805). What is the proper way to code those?

 

[nielynco]

Hey Everyone,

When a patient comes in for a transabdominal viability/dating ultrasound, but she ends up being in her 2nd trimester between 14 & 18 weeks gestation, how are you coding those? They're basically documenting a 1st trimester viability scan (76801) with maternal and fetal structures, but the patient is a bit further along and it's too soon to do a complete anatomy scan (76805). What is the proper way to code those?

CPT has always stated that if less the required elements are documented, viewed for a particular ultrasound code, you report the one that does describe was what actually was done. In this case if the documentation only meets the requirements of 76801, then that is the code you report irrespective of age. The gestational age in the code description are meant to typify what you would be able to observe at that age.