Yen Posted Fri 26th of October, 2012 22:49:05 PM
Is there a CPT code for both pelvic and vaginal ultrasound, or do we need to use CPT 76830 and 76856 separately?
SuperCoder Answered Mon 29th of October, 2012 13:34:22 PM
You may code for both ultrasounds as long as they are both medically necessary and ordered by the gynecologist.
Report 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) and 76830 (Ultrasound, transvaginal). Depending on your payer’s rules, you may need to append modifier 51 Multiple procedures) to 76830.
Why: CPT guidelines say that if you perform a transvaginal examination in addition to a transabdominal nonobstetric ultrasound, you should report 76830 in addition to the appropriate transabdominal exam code. Remember: CMS requires that the treating physician--in this case, the gynecologist--order diagnostic tests. The request and report should convey the medical necessity for both exams.