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Level 2 Obstetrical Sonogram

Pessie Posted Thu 06th of December, 2012 00:38:47 AM

what is the right way to code :
Level 2 Obstetrical Sonogram:
sonographic evaluation using a curvilinear transducer

Pessie Posted Thu 06th of December, 2012 20:25:17 PM

History: Evaluate fetal anatomy. By the patient's first trimester ultrasound performed at her physician's office the estimated gestational age is 22 weeks and one day.
Findings: There is a single live intrauterine gestation identified in breech position. The placenta is posterior and away from the internal cervical os. The amniotic fluid volume is within normal limits with amniotic fluid index of 10.9 CM. The cervix measures 3.7 CM in length.
Do you need more information to find the right codes? We are having some difficulty getting reimbursed. Thanks

SuperCoder Answered Thu 06th of December, 2012 21:30:05 PM

The January 2003 CPT book published by the American Medical Association contains a new code (76811) for a procedure described as “Ultrasound, pregnant uterus, real time with image documentation, maternal evaluation plus detailed fetal anatomic examination, transabdominal, single or first gestation”. This new code is intended to describe the extensive fetal examinations that have become possible over the last decade and that have variously been known as “Level II”, “targeted”, “comprehensive” or “genetic” scans.

Because this new code will be assigned more RVUs than the basic obstetrical sonogram (76805), the Society for Maternal-Fetal Medicine believes that the new code describes an examination involving significantly more work, and requiring greater expertise than that required for 76805. Additionally, sophisticated equipment, rather than typical office level ultrasound machines, will be required to obtain the necessary imaging detail.

The work included under this new code can be divided into that occurring before, during and after the actual ultrasound. Particularly for the identification of fetal anomalies, there is greater importance in ensuring that proper historic information is available before the technical performance of the ultrasound, and that proper counseling occurs after the images are obtained. Therefore it is essential to recognize that the additional technologic sophistication and imaging expertise are merely the tip of the iceberg in meeting the requirements of CPT 76811.

The pre-service work includes review of clinical information, including relevant personal and family history, exposures and other risk factors. It also includes review of pertinent prior imaging study reports or the images themselves as available.

The intra-service work includes performance of the examination or supervision of the sonographer performing the examination, and interpretation of the examination. It is not possible to specify all of the possible components of this examination, and in any case the proper components will vary with the clinical needs of the patient.

The clinical service encompassed by CPT code 76811 will include all of the components of the complete obstetrical sonogram (CPT 76805), which has been defined similarly by the American College of Obstetricians and Gynecologists, the American College of Radiology, the American Institute of Ultrasound in Medicine, and the Society for Maternal-Fetal Medicine.

Pessie Posted Thu 06th of December, 2012 22:53:13 PM


SuperCoder Answered Thu 06th of December, 2012 23:16:22 PM

You should identify the reason for the scan using the appropriate ICD-9 code. If this ultrasound is a routine screening, you should use only V28.3 (Screening for malformation using ultrasonics) or V28.81 (Encounter for fetal anatomic survey).The routine ultrasound code 76805 does not include a detailed fetal anatomic examination, experts say. This separates a routine ultrasound from a detailed/targeted one.Hence I would recommend using V28.3

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