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Transvaginal Ultrasound

January 25, 2017
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Question:

Is there a way to code for a transvaginal ultrasound for a second fetus

Answer:

There are several codes that may apply to this scenario as noted below:

76813 (Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation)

76814 (Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure))

76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal)

Which code is most appropriate will depend upon your scenario. However, you’ll note there is no “each additional gestation” code associated with 76817. Therefore, 76817 is the only code that would be reported if 76813/76814 are not appropriate.

Here is a related November 2011 AMA CPT® Assistant which notes that CPT code 76817 includes the evaluation of twin fetuses as noted below:

CPT® Assistant November 2011

“Question:
Does code 76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal, include the evaluation of both twin fetuses?

Answer:
Yes. Code 76817 describes obstetrical ultrasound evaluation via the transvaginal approach and includes evaluation of embryo(s) and gestational sac(s) and evaluation of maternal uterus, adnexa, and/or cervix. Code 76817 distinguishes between an obstetric transvaginal ultrasound and a non-obstetric transvaginal ultrasound (76830), and may be reported in addition to a transabdominal approach (76816) when necessary, to adequately view the structures.

Code 76816, Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation 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, differs from code 76817 in that it is reported for each fetus after the first. Code 76816 describes an examination designed to reassess fetal size and interval growth or to reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound. Code 76816 should be coded once for each fetus requiring reevaluation. Modifier 59, Distinct Procedural Service, should be appended for each fetus after the first to reflect the repetitive work for second or third fetus examinations.

To further clarify, for transvaginal examinations performed for non-obstetrical purposes, code 76830, Ultrasound, transvaginal, should be reported.”

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