Patient was having abdominal and vaginal pain. Had a very faintly positive urine pregnancy test. Dr. performed a transvaginal ultrasound to confirm viable intrauterine pregnancy and found no gestational sac or fetal pole. Will this ultrasound be coded as an OB transvaginal ultrasound or a non-obstetrical transvaginal ultrasound?
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Wiki OB ultrasound vs Non-obstetrical Ultrasound
- Thread starter PennyG
- Start date
natashalage
Guru
Hi, I am a new coder. I would code non-OB US because: OB care was not established yet, new pt comes for a new condition, US is done but found not pregnant = Non-OB US. If US showed positive for pregnancy, then yes, OB US 76815.
Hi, for my two cents, I would code as OB based on this information from ACR/CPT. In this case, the indications are pregnancy related.
CPT states, through its companion publication, the CPT Assistant,5 that the use of OB ultrasound codes are appropriate anytime the patient has been established to be pregnant, by any method or means, and the indications for the ultrasound study might be or could be pregnancy-related, regardless of whether the outcome might not confirm a pregnancy, or might produce a diagnosis that is not pregnancy-related. For the patient who has not been diagnosed as pregnant, and the indications for the ultrasound study are not pregnancy-related, the use of non-OB ultrasound codes is appropriate, regardless of whether the outcome of the study shows a pregnancy or complication related to pregnancy.
CPT states, through its companion publication, the CPT Assistant,5 that the use of OB ultrasound codes are appropriate anytime the patient has been established to be pregnant, by any method or means, and the indications for the ultrasound study might be or could be pregnancy-related, regardless of whether the outcome might not confirm a pregnancy, or might produce a diagnosis that is not pregnancy-related. For the patient who has not been diagnosed as pregnant, and the indications for the ultrasound study are not pregnancy-related, the use of non-OB ultrasound codes is appropriate, regardless of whether the outcome of the study shows a pregnancy or complication related to pregnancy.
natashalage
Guru
Yes, I would definitely use Cmama12's advice because she has a vast experience in OBGYN. I've seen her participation in this forum for many years- Thank you! 
Also, thank you for the great article. I will read it thoroughly and learn.
Also, thank you for the great article. I will read it thoroughly and learn.