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Reader Question: Reason for Imaging Guides Your Coding

- Published on Thu, Dec 15, 2016

Question: Our physician did a pelvic ultrasound on a patient who complained of pelvic pain. Incidentally, our physician discovered that the patient was pregnant. How can we report these services? Is there a code for incidental pregnancy?

Kansas Subscriber

Answer: You should select the code for pelvic ultrasound depending upon the reason of the examination. Since the patient underwent imaging for pelvic pain, you should submit code 76856 (Ultrasound, pelvic [nonobstetric], real time with image documentation; complete) for the pelvic ultrasound.

Codes for obstetric ultrasound: If your physician would have done the pelvic ultrasound in a patient who was confirmed being pregnant with a positive pregnancy test, then regardless of findings you would choose from codes: 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) - 76817(Ultrasound, pregnant uterus, real time with image documentation, transvaginal).

Add the diagnosis codes: The diagnosis code in this situation would be the primary reason for the scan, i.e. pelvic pain. You should submit code R10.2 (Pelvic and perineal pain) for this diagnosis. For the secondary diagnosis of an incidental pregnancy, you will submit code Z33.1 (Pregnant state, incidental). Another possible code may be Z32.01 (Encounter for pregnancy test, result positive).

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