Ultrasound first trimester

sullivak

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Sorry if this question is too basic, but I am new to OB coding. I'm struggling with OB ultrasounds that occur early in the first trimester, when it doesn't seem possible to measure all of the elements that CPT states are needed to code a complete exam 76801.

Here's an example-
Clinical Data: Vaginal spotting. Positive pregnancy test.
OBSTETRIC <14 WK ULTRASOUND:

Technique: Transabdominal ultrasound was performed for evaluation
of the gestation as well as the maternal uterus and adnexal
regions.

Comparison: None.

Intrauterine gestational sac: Visualized/normal in shape.

Yolk sac: Present

Embryo: Present

Cardiac Activity: Present

Heart Rate: 167 bpm

MSD: mm w d

CRL: 18 mm 08w 2d

US EDC: 12/10/2012

Maternal uterus/Adnexae:
Nonvisualization of the ovaries. Uterus appears within normal
limits. No subchorionic hemorrhage. No free fluid.

IMPRESSION:
Single viable intrauterine pregnancy with estimated gestational age
8 weeks 2 days. Fetal heart tones of 167 beats per minute. Follow-
up anatomic ultrasound recommended at 20 weeks, or sooner if
clinically indicated.
---
Can this be coded as a 76801 even though it doesn't include a measurement of amniotic fluid volume? :confused: I think I've heard that the fluid volume cannot be measured so early in the pregnancy.
Thanks,
Kim
 

jgf-CPC

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It is a very limited study before 14 weeks of gestation. So, if the ultrasound is done at an early part of gestation, it will be truly difficult to document all the features. That is the reason why such situations are categorized to limited, i.e., 76801 with less than 14 weeks gestation. So, it is no harm if it says "not applicable" for certain features as amniotic fluid, but the rest of the findings justifies the OB findings, and we can code 76801.
 

sullivak

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Thanks, Jackie. I suspected as much. Some have told me that you can only code a 76815 in this situation - but it's my understanding that 76815 is really just for a "quick look" ultrasound.
 
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