The pregnancy status of the patient and the purpose of the ultrasound examination determine the proper code.
â€¢ Transabdominal ultrasound:
â€¢ When the patient is known to be pregnant and the physician is utilizing ultrasound to evaluate the pregnancy or a suspected complication of, or to the pregnancy, then the obstetric pelvic codes should be used (76815).
â€¢ When the patient is not pregnant, or the status of the pregnancy is unknown prior to the examination, and the ultrasound is used to evaluate pelvic pain, amenorrhea, vaginal bleeding or non-gynecologic pelvic pathology, then the non-obstetric codes should be used (76857) and if it is for complete use- 76856.
â€¢ Transvaginal ultrasound
â€¢ Prior to 2004 there was a single code for transvaginal ultrasound that did not differentiate between pregnant and non-pregnant patients. Now, there are two codes depending on the pregnancy status.
â€¢ If the patient is pregnant use the code (76817).
â€¢ If the patient is NOT pregnant use the code (76830).
â€¢ It is important to note that there is only a complete exam code for transvaginal ultrasound. Many emergency department transvaginal ultrasounds are less than complete exams, thus it is appropriate to use the modifier -52 Reduced Services.
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