Reimbursement Advisor

Obstetric ultrasound with no maternal evaluation

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<huc>Q</huc> We received an error from an auditor regarding radiology readings for obstetric ultrasounds. We looked at the size and date of the fetus, and didn’t document a maternal evaluation (the cervix, however, was documented).

For transabdominal, we use 76801 (Ultrasound, pregnant uterus, real time with image documentation, fetal & maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation) or 76805 (…after first trimester [14 weeks 0 days]). The auditor tells us that, when the maternal evaluation isn’t documented, we should use 76816 (Ultrasound, pregnant uterus, real time with image documentation, follow-up [eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan], transabdominal approach, per fetus)

My impression was that 76816 is for follow-up ultrasound only. When we requested clarification, the auditor replied that this code was for either assessment or reassessment.

<huc>A</huc> In this case, the auditor is not interpreting the follow-up code correctly. The nomenclature clearly states that 76816 is for a reevaluation, not an initial assessment.

The auditor is correct, however, that you have not documented all the required elements for the codes you are billing.

Maternal evaluation is required under both CPT and American College of Radiology/American Institute of Ultrasound in Medicine (ACR/AIUM) rules. To bill 76801, ACR/AIUM requires location and number of gestational sacs, crown-rump length, presence or absence of fetal life, evaluation of uterus (including cervix), and adnexa. The guidelines for code 76805 use similar language.

Your coding options will depend on the fetal gestation: If the fetus is less than 14 weeks, consider billing a limited ultrasound (76815: Ultrasound, pregnant uterus, real time with image documentation, limited [eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume], one or more fetuses) instead of 76801 when maternal structures are not documented. You could also add a “reduced services” modifier (-52) to the code.

Modifier -52 is an even better choice when the fetus is past 14 weeks, since fetal scrutiny is greater than it is for the younger fetus.

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