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OB Transvaginal ultrasound

Karen Posted Mon 26th of September, 2016 16:14:26 PM
we have a lot of confusion when it comes to our OB ultrasounds. ****When we are early in the pregnancy and we are doing an ultrasound for dating we use the 76801 with the Z34.0_. If any part of the elements are not documented then we must down code to the 76815; per everything I have read. **Now if we are doing a transvaginal ultrasound early in the pregnancy it is my understanding that the same elements are required as in the 76801. SO the questions is if the 76801 can be down coded to the 76815; WHAT happens if we are doing a transvaginal and all the elements are not documented. HOW do we bill for that? Thank you, Karen.
SuperCoder Answered Tue 27th of September, 2016 03:25:48 AM

Greetings from SuperCoder!


Occasionally, the radiologists use a transvaginal ultrasound when she evaluates a multiple-gestation patient. Transvaginal ultrasounds may be reported separate or in addition to one of the transabdominal ultrasounds.


For transvaginal ultrasounds, you should report 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) only once.


Remember, all obstetrical ultrasounds are transabdominal except 76817, and your physician may have to do a transvaginal in addition to a transabdominal exam. If your physician performs both types of ultrasounds during the same visit, you can report both. But keep in mind, you must have separate reports for both approaches. Also, document the ICD-10 codes that support the medical necessity for conducting both abdominal and vaginal examinations.


Please feel free to write if you have any concern/query.



Karen Posted Thu 29th of September, 2016 08:05:47 AM
That really did not answer my question. If we don't have all the elements of the transvaginal ultrasound 76817 how do we code this? As with 76801, if we don't have all the elements we down code to 76815. What do we do with the 76817? Thanks
SuperCoder Answered Fri 30th of September, 2016 03:47:04 AM

Greetings from SuperCoder!


As per CPT guidelines, codes 76801, 76802, 76805, 76810, 76811, and 76812 have the concept of “assessment of all elements” to make it complete. So if all these elements are not completed, then code 76815 (limited to the assessment of one or more elements) should be reported. But code 76817 does not have such guideline regarding complete or limited assessment, so there is no need to worry about that.


I hope it makes sense.



Karen Posted Fri 30th of September, 2016 09:10:07 AM
Thank you very much, this helps me tremendously. Karen
SuperCoder Answered Mon 03rd of October, 2016 01:37:48 AM

Greetings from SuperCoder!

We are always happy to help you.


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