Vangie Posted Tue 10th of May, 2011 22:11:04 PM
Please help. How would I code this procedure?
Patient presenting to clinic for prenatal care. She appears comfortable. Denies vaginal bleeding, leakage of fluid, or contractions. She reports fetal movements. A nonstress test was performed and was noted to be reactive.
Following this a transadominal ultrasound was performed. Fetus was noted to be in vertex presentation with anterior placenta. Amniotic fluid index was calculated and noted to be satisfactory at 10.1 cm.
Measurement of biparietal diameter: Head circumference, abdominal circumference and femur length indicated estimated fetal weight of 2475 g which indicates a growth at 50th percentil.
Pregnancy complicated by diabetes mellitus, controlled with dietary modification.
I coded this as follows:
76815 Transbdominal ultrasound
76818/59 Fetal biophysical profile with NST.
SuperCoder Answered Wed 11th of May, 2011 03:31:11 AM
You should not use 59 modifier because there is no bundling between these two codes. Report simply like
SuperCoder Answered Wed 11th of May, 2011 10:36:48 AM
Everything alright as mentioned Birendra, but I wanted to focus on the distinctive features that would justify your coding criteria:
As per ACOG, Code 76818 includes performance and documentation of the following assessments:
· Fetal non-stress test
· Fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutes)
· Fetal movements (three or more discrete body or limb movements within 30 minutes)
· Fetal tone (one or more episodes of fetal extremity extension
with return to flexion)
· Quantification of amniotic fluid volume (a pocket of amniotic fluid that measures at least 1 cm in two planes perpendicular to each other)
Now, you can check what additional features are there to code 76815 and does it distinctively justify that. Yes, the pelvimetry here. There is really a thin line to distinguish, no need of modifier 59.