Wiki First Trimester Transabdominal & Transvaginal U/S

[dmarshall]

Hi OB/GYN,

I need OB ultrasound education/advice please, our sonographer scanned this OB patient and our Attending submitted TV and TA codes, I asked the Attending this question: Both a TV/TA US was done due to suboptimal views, but I do not see where the qualitative assessment of amniotic fluid was noted, or the placenta structure was viewed. Would you please review regarding these elements and let me know if I am missing seeing it in the report. If not, may I ask that a note in the report state that a survey of placental anatomic structure and the AFI could not be performed and note the reason why it was not done. I may be able to bill out the TV only if no adjustments are made. I am submitting the report below:

Indication Dating
Maternal Assessment Physical Exam Done
Method Transabdominal and transvaginal ultrasound examination. View: Sufficient
Pregnancy Singleton pregnancy. Number of embryos: 1
Dating Date Details Gest. age EDD
LMP 2/13/2023 8 w + 3 d 11/20/2023
U/S 4/13/2023 based upon CRL 6 w + 2 d 12/5/2023
Assigned dating based on the LMP, selected on 04/13/2023 8 w + 3 d 11/20/2023
Assessment Gestational sac: visualized. Location: intrauterine
Yolk sac: visualized
Embryo: visualized
Cardiac activity: absent
GS 19.9 mm 6w 6d 2% Rempen
YS 3.1 mm <1% Grisolia
CRL 5.2 mm 6w 2d <1% Hadlock
Maternal Structures:
Uterus Size 94 mm x 113 mm x 81 mm. Vol 452.9 cm³
Cervix Cervical length 50.2 mm
Right Ovary WNL
Size 37 mm x 22 mm x 28 mm. Vol 11.8 cm³
Corpus luteum: hemorrhagic
Left Ovary WNL
Size 30 mm x 15 mm x 23 mm. Vol 5.3 cm³

Impression:
Transvaginal and transabdominal approaches were used due to suboptimal views.
Uterus is enlarged due to pregnancy and fibroids.
Intrauterine pregnancy seen. Gestational sac is distorted, hematoma is noted and isoechoic
area with increased vasculature. Cannot exclude partial molar.
Calcified yolk sac present. Embryo without a heart beat.
Intramural fibroid on the right ~ 7 cm in diameter and subserosal/intramural fibroid fundal
area on the right ~ 3.25 cm in diameter.
Both ovaries are WNL, right ovary is with corpus luteum.
No free fluid in cul de sac.
No tenderness on the exam.
Follow-up as clinically indicated.
Coding Procedures 76801: 1st Trimester Ultrasound
76817: Transvaginal Ultrasound OB

The Attending states this particular patient had a difficult scan due to presence of fibroids, and required transabdominal to obtain sufficient views. The specific things about this scan were mentioned in the report (distorted sac, hematoma, cannot exclude partial molar)- do I need additional information? The Attending also mentioned that It seemed that the pertinent clinical findings were focused on, and the fluid/placenta at this gestational age and in this case was not pertinent.

Does this qualify for 76801 & 76817? Or am I overthinking the whole thing. I'm wanting to understand what are the specific components needed for billing, the descriptions on this report are detailed but not sure if sufficient for billing. Does the report need to indicate what was viewed TV and what was viewed TA? Thank you so much and any information is greatly welcome.

Dorine Marshall,CPC,COBGC
Oklahoma State University
Tulsa, Ok

 

[Cmama12]

Hi, this is the information we follow - CPT states “placenta and fetal structure when visible”, so that will not always have specific results under 11 weeks. They will only comment if something is visible.

The sac and fluid we can give credit to under 11 weeks if they mention the presence of a yolk sac or gestational sac as CPT also states it like this “amniotic fluid volume/gestational sac shape”-the fluid is in this sac and unmeasurable before 11 weeks. IMO, you can code both here. Often they only do TV at this early gest age and note explains why both were done. Often when the pregnancy is more advanced, they will add a TV for cervical length. As far as I am aware, there are no specific requirements for saying what was viewed with which method, but the note should stated the approaches used as your example does.

 

[dmarshall]

Hi, this is the information we follow - CPT states “placenta and fetal structure when visible”, so that will not always have specific results under 11 weeks. They will only comment if something is visible.

The sac and fluid we can give credit to under 11 weeks if they mention the presence of a yolk sac or gestational sac as CPT also states it like this “amniotic fluid volume/gestational sac shape”-the fluid is in this sac and unmeasurable before 11 weeks. IMO, you can code both here. Often they only do TV at this early gest age and note explains why both were done. Often when the pregnancy is more advanced, they will add a TV for cervical length. As far as I am aware, there are no specific requirements for saying what was viewed with which method, but the note should stated the approaches used as your example does.

Thank you so much for your response and education, much appreciated, I feel more confident to bill out the two codes now. I was unaware that the sac and fluid could be given credit under 11 weeks if the presence of a yolk or gestational sac was mentioned, I have not seen this noted in the ACR, AIUM, or CPT guidelines, so again, thank you.