Minerva Posted Tue 10th of May, 2011 21:55:33 PM
cpt states that certain documentation requirements have to be met in order to bill for the above. if the physician states in his documentation under placenta location:not applicable and states the same not applicable under amniotic fluid volume can we still bill the 76801. all other required elements have been documented except the not applicable statement. I'm not sure I can still bill the 76801.
SuperCoder Answered Wed 11th of May, 2011 11:06:28 AM
To code 76801: It is a very limited study before 14 weeks of gestation. So, if the ultrasound done at an early part of gestation, it will be truly difficult to document all the features. That is the reason, why such situations are categorized to limited, i.e., 76801 with less than 14 weeks gestation. So, it is no harm if it says "not applicable" for certain features as above, but rest of the findings justifies the OB probe findings, and we can code 76801.
The question arises when the indication of the report doesn't justify if it was an exam with an OB probe or non-OB probe. In that situation only, if we are sure it is a non-OB exam/OB exam, then we can code, but in case of a confusion, we can send for clarification.