Coding obstetrical (OB) ultrasounds can be challenging because there are many Current Procedural Terminology (CPT®) codes to choose from. Each code description should be reviewed carefully along with the ultrasound guidelines to make sure you are selecting the correct code.
CPT codes used for OB ultrasounds are 76801-76821. The description of the codes are based on whether the study is complete or limited, transabdominal and/or transvaginal, age of fetus, a follow-up study, biophysical profile, nuchal translucency measurement, and fetal umbilical or middle cerebral artery Doppler. Choosing the correct code is based on the documentation in the report.
What is a complete OB Ultrasound?
The CPT description noted at the beginning of the OB ultrasound code range states that a complete exam for a fetus less than 14 weeks and 0 days must include "determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation, survey of visible fetal and placental anatomic structure, qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa".1 If all elements are documented, 76801 would be assigned. If more than one fetus is documented, 76802 is assigned per each additional gestation in addition to 76801.
Note that the description for a complete exam for a fetus 14 weeks and 0 days and older is slightly different. This must include "determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age, survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and, when visible, examination of maternal adnexa".2 If all elements are documented, 76805 would be assigned and 76810 for each additional gestation.
"If a complete study is intended, but one of the required elements cannot be visualized (e.g., obscured by bowel gas or surgically absent), the reason for non-visualization must be documented in the report in order to assign a complete study CPT. Without this documentation, the limited study code, 76815, should be assigned."3 When documented, a transvaginal study, 76817, may be billed in addition to the transabdominal study. This code may only be used one time regardless of the number of fetuses documented.
Other OB Ultrasound Codes
Code 76815 is used to code a limited exam when all elements needed to code a complete exam are not documented in the report. This code is often used when only a "quick look" is necessary to assess one or more specific elements such as amniotic fluid, fetal weight, etc. This code may only be used once regardless of the number of gestations/fetuses.
Code 76816 is used to bill a follow-up study. The study is done to reassess size and interval growth or an abnormality previously discovered on a prior ultrasound. This code may be used once for each fetus requiring reevaluation and adding modifier 59 to each additional code.
Codes 76811 and 76812 (each additional fetus) include all elements in 76805/76810, "plus detailed anatomic evaluation of the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, abdominal organ specific anatomy, number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated."4 This exam is rarely done and is usually performed when there is a high risk of fetal birth defects.
Code 76819 is a biophysical profile study using ultrasound. There are four elements required to bill for this study: amniotic fluid volume, breathing, gross body movements, and fine motor movements. Each element is given a quantity of 0-2. For example, if the amniotic fluid is normal, it might get a "2" or if there is no fetal movement at the time of the study, it might receive a "0." Often times, the report will note in the impression "biophysical profile is 8/8" meaning the exam was normal for all elements. This code may be used per fetus with a modifier 59 for each additional fetus and may be used in addition to other OB ultrasound codes, if both procedures are performed and documented.
OB versus Non-OB Ultrasounds
There may be instances where the report is unclear as to whether the exam being performed is an OB or non-OB ultrasound. One clear way to determine this is by the clinical indication/reason for the exam. If the documentation states that the order is for a female pelvic ultrasound and there is no indication the patient is pregnant and a pregnancy is found, the exam is reported as a non-OB ultrasound, using codes 76856 (complete, pelvic ultrasound), 76857 (limited or follow-up ultrasound) and/or 76830 (transvaginal ultrasound). On the other hand, if an OB ultrasound is ordered and the report documents the patient is pregnant and no pregnancy if found, it is reported as an OB ultrasound. Per the American College of Radiology, "the use of OB ultrasound codes are appropriate anytime the patient has been established to be pregnant, by any method or means, and the indications for the ultrasound study might be or could be pregnancy-related, regardless of whether the outcome might not confirm a pregnancy, or might produce a diagnosis that is not pregnancy-related."5
For the patient who has not been diagnosed as pregnant and the indications for the ultrasound study are not pregnancy-related, the use of non-OB ultrasound codes is appropriate, regardless of whether the outcome of the study shows a pregnancy or a complication related to pregnancy.
In summary, carefully read the reports making sure all elements are documented before coding a complete exam. If the report is unclear as to whether it is an OB or Non-OB exam, query the physician for additional information.