Descriptions and Required Components for CPT 76805, 76815 and 76816 ultrasound procedures
Recently, our membership has had questions regarding the appropriate use and required components of CPT codes 76805, 76816 and 76815. This coding tip reviews the components of each imaging study, as well as provides some clinical scenarios of appropriate use:
It is important to distinguish, perform and document the required components for the common obstetric ultrasound procedures described below.
76805. Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach, single or first gestation
Required components, whether visualized or not (should be documented):
Head and neck:
• Lateral cerebral ventricles
• Choroid plexus (right and left)
• Midline falx
• Cavum septi pellucidi
• Cerebellum
• Cisterna magna
Face:
• Upper lip
Chest:
• Cardiac activity
• Four chamber view
• Left ventricular outflow tract
• Right ventricular outflow tract
Abdomen:
• Stomach (presence, size, and situs)
• Kidneys
• Urinary bladder
• Cord insertion site into fetal abdomen
• Umbilical cord and vessel number
Spine:
• Cervical
• Thoracic
• Lumbar
• Sacral spine
Extremities:
• Legs
• Arms
Placenta:
• Placenta location
• Relationship to internal os
• Appearance
• Placental cord insertion
Standard evaluation:
• Fetal number
• Presentation
• Qualitative or semi-qualitative estimate of amniotic fluid
Biometry:
• BPD
• Head circumference
• Femur length
• Abdominal circumference
• Fetal weight estimate
Maternal anatomy:
• Cervix (separate transvaginal when indicated)
• Uterus
• Adnexa (even if ovaries not visualized)
76815 Ultrasound, pregnant uterus, limited (fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses
One or more of the following components only:
· Fetal heart beat
· Placental location
· Fetal position
· Qualitative amniotic fluid volume
76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), trans-abdominal approach, per fetus
The use of this CPT code is reserved for subsequent follow up ultrasound only; i.e. An ultrasound must have been performed previously.
Components include: Focused assessment of fetal size by measuring BPD, abdominal circumference, femur length, or other appropriate measurement; and amniotic fluid volume
OR
Detailed re-examination of a specific organ or system known or suspected to be abnormal.
Sample Clinical Scenarios:
Appropriate code: 76815
2. Patient seen in office for routine screening second trimester anatomy ultrasound. Patient is low risk with no medical problems or suspected or known fetal abnormalities.
Appropriate code: 76805
3. Patient seen in office for follow up ultrasound for re-examination of fetal kidneys. A previous ultrasound has been performed evaluating anatomy.
Appropriate code: 76816
4. Patient seen in office for targeted follow up fetal growth and amniotic fluid assessment. Fetal anatomy is not evaluated. A previous ultrasound has been performed evaluating anatomy.
Appropriate code: 76816
5. Patient seen in office for evaluation of for placental location. Only placental location and amniotic fluid volume are evaluated on transabdominal ultrasound only. Fetal growth and maternal or fetal anatomy are not evaluated.
Appropriate code: 76815