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Thread: US CPT Coding

  1. #1

    Exclamation US CPT Coding

    AAPC: Back to School
    [B]PLEASE SEE THE BELOW REPORT...SHOULD THE CPT CODES BE 76815, 76817 or 76857, 76830?

    INDICATION: Near-syncope and pregnancy.


    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.


    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


  2. #2
    Join Date
    Apr 2007
    Lubbock, TX


    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...

  3. #3


    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,
    Anthony McCallum, CPC, CIRCC, CPC-I, CCS

  4. #4


    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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