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Reimbursement Advisor

Focus on Obstetric Ultrasound

September 2003 · Vol. 15, No. 9

<huc>Q</huc> Are CPT 76805 and 76811 different? Both are for fetal and maternal ultrasound evaluation, yet 76811 includes a detailed fetal anatomic exam. Our ultrasonographer says she always does a detailed fetal exam.

<huc>A</huc> Code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus a detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires both basic examination of fetal and maternal structures included with code 76805 (determination of number of fetuses and amniotic/chorionic sacs; measurements appropriate for gestational age; survey of intracranial, spinal, and abdominal anatomy; 4-chambered heart; umbilical cord insertion site; placenta location; amniotic fluid assessment; and maternal adnexa), and a detailed examination of fetal anatomy. This includes evaluation of fetal brain and ventricles; face; heart and outflow tracts and chest anatomy; abdominal organ-specific anatomy; number, length, and architecture of limbs; and detailed evaluation of the umbilical cord, placenta, and other fetal anatomy that may be clinically indicated.

Smaller, office ultrasound machines cannot perform this detailed exam. Larger, more sophisticated machines found in radiology departments are required; some maternal-fetal specialists’ offices also have such equipment. A detailed examination is not warranted in every case just because the required machine is handy. The key to use of code 76811 is medical justification (eg, a suspected fetal problem).

<huc>Q</huc> If a patient is scanned both transvaginally and transabdominally in the first trimester, can I use both code 76801 and code 76817?

<huc>A</huc> Since the first trimester encompasses pregnancy through 14 weeks’ gestation (equal to 14 weeks, 0 days), check the patient record for gestation on the date of the scan to be sure. If the patient is less than 14 weeks, 0 days of gestation, and the documentation shows both a fetal and maternal evaluation, the correct code would be 76801 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester [<14 weeks, 0 days], transabdominal approach; single or first gestation). CPT now notes that a transvaginal and transabdominal ultrasound may be reported together. That means both coding choices—76801 and 76817—are correct.

Make sure that there are 2 reports—1 for the abdominal and 1 for the vaginal scan—and that both are medically indicated. Also, since you are doing multiple scans in 1 encounter, add a modifier-51 (multiple procedure) to the code with the lower relative value.

Which code takes modifier-51? It depends on whether you bill for the professional and technical components (you own the machine) or just the professional part (physician provides the interpretation and report only), because the 3 relative-value components assigned to each code add up differently.

If you bill the complete service, use 76817, 76801-51. If you bill for the professional component only (which means you need to add the modifier -26 to both codes), the reverse is true: Use codes 76801-26, 76817-26-51.

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