Documenting Reasons for Non-Visualization During OB Ultrasound Exams
Authors: The Society for Maternal-Fetal Medicine (SMFM) Coding Committee; Steve Rad, MD, FACOG, Chair; Daphne Landau, MD and Betzaida Martinez, CPC, CPMA, COBGC, CPPM
Learn more about proper documentation for non-visualized structures during OB ultrasound in this month's Coding Tip.
Accurate documentation of reasons for non-visualization of components during an OB ultrasound exam is essential for compliance with AMA CPT ultrasound guidelines and AIUM. To report a complete examination, the report must document all components of the exam, including the stated results of the evaluation of each element or the reason for non-visualization. This documentation serves to demonstrate that all required elements of the study were attempted and to support the completeness of the examination.
View case scenarios, sample reports, and more by downloading the PDF.