sullivak
Guru
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? I think I've heard that the fluid volume cannot be measured so early in the pregnancy.
Thanks,
Kim
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? I think I've heard that the fluid volume cannot be measured so early in the pregnancy.
Thanks,
Kim