Second, there is sometimes confusion about assignment of an OB ultrasound code vs an abdominal or non-OB pelvic ultrasound code.
When the pregnancy is in the first trimester (less than 14 weeks), the coder should remember that the required elements for CPT® code 76801 will be those that are "appropriate for gestation" and "visible." If any of the elements listed in the CPT code book are not able to be measured or are not visible, then the report should document that information in order to assign 76801.
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Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
Copyright December 2016 by the American College of Obstetricians and Gynecologists. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Received October 21, 2016 Accepted October 21, 2016 Obstetric ultrasound examinations are performed with a transabdominal, transvaginal, or transperineal approach.
Other codes in the OB ultrasound section of CPT® include 76816, a special code for follow-up examinations of fetal size or fetal organ systems; 76818 through 76821 for biophysical profiling and Doppler velocimetry; and 7684, nuchal translucency measurement codes that were described recently in the September/October 2006 ACR Radiology Coding Source as part of the 2007 CPT® code update.
The first-trimester ultrasound examination is used mainly to confirm intrauterine pregnancy, to confirm dating, and to assess nuchal translucency.
The uterus, cervix, and adnexa should be evaluated for location of a gestational sac.
Portions of this Practice Bulletin were developed from collaborative documents with the American College of Radiology and the American Institute of Ultrasound in Medicine (1, 2).
Committee on Practice Bulletins—Obstetrics and American Institute of Ultrasound in Medicine.