US CPT Coding

jdavenport02

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PLEASE SEE THE BELOW REPORT...SHOULD THE CPT CODES BE 76815, 76817 or 76857, 76830?
TRANSABDOMINAL AND TRANSVAGINAL PELVIC SONOGRAM:

INDICATION: Near-syncope and pregnancy.

TRANSABDOMINAL:

FINDINGS: The uterus measures 8.9 x 3.5 x 4.2 cm, the right ovary 2.4 x
3.6 x 1.7 cm, and the left ovary 2.5 x 3.0 x 2.1 cm. There is small
amount of free fluid around the right ovary.

TRANSVAGINAL:

FINDINGS: Transvaginal imaging shows no evidence for intrauterine
pregnancy. There is small amount of anechoic free fluid in the
cul-de-sac. No adnexal masses are seen. There is flow in the ovaries.

The endometrial echo complex is about 4 mm in thickness. The left
ovary is 2 x 3 x 2.1 cm and the right ovary 4.1 x 2.7 x 3.1 cm with
transvaginal imaging.

IMPRESSION: Small amount of free fluid in the pelvis. No intrauterine
pregnancy. No adnexal masses. Followup quantitative beta-hCG is
recommended.


Thanks!
 

btadlock1

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Oooh...that's tricky... I'd probably go with 76801 and 76817, since the intent of the US was to assess a suspected pregnancy, and the focus was on the maternal anatomy relevant to a pregnancy. I wouldn't use a non-obstetrical code on this paticular visit - Maybe if she has another US in the future after the second blood test indicates that she's not pregnant. I'd like to know how an OBGYN coder would code this, as well - I'd think it would be treated similar to a suspected ectopic pregnancy, but I'm just guessing and could be completely wrong about that...
 

ciphermed

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There is a CPT Assistant, Clinical Example (2001) which indicates that if the pregnancy was "definitely known" based on previous diagnostic studies or physician evaluation and the US does not currently demonstrate an IUP; the Obstetrical US codes should be used as the US was ordered based on the indication that it may have been pregnancy related.

Hope this helps,
 
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I currently code radiology and agree with ciphermed, if there was a known pregnancy previous to this U/S either via preious U/S, beta hcg or both then it would be coded with the pregnancy codes versus the non-obstetrical.
 
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