ACR Radiology Coding Source™ January-February 2003

Most significant of the radiology CPT® coding changes for 2003 were the revision of the pelvic ultrasound section and the provision of detailed guidelines for the use of the new and revised obstetrical ultrasound codes.

The American College of Radiology, in conjunction with a number of other specialty societies, formed a task force to develop a code describing a more detailed evaluation and measurement procedure for fetal characteristics. The task force also reviewed the obstetrical ultrasound codes and determined that revisions were needed, along with some new codes more in tune with recent advances in technology. The group recommended that the prior "Pelvic" ultrasound section be divided into "Obstetrical" and "Nonobstetrical" subsections, that five new codes (76801, 76802, 76811, 76812, and 76817) be added and that four code descriptors (76805, 76810, 76815, 76816) be revised. The CPT® Editorial Panel accepted the recommendations and established two new subheadings under the Diagnostic Ultrasound Pelvis section to differentiate between obstetrical and nonobstetrical codes.

Detailed introductory notes are provided in the CPT® 2003 Manual under the "obstetrical" ultrasound section. This section provides extensive comments on what should be included in each exam. Note that documentation must be provided in the radiology report that describes all the elements required for the study. If all the elements required for the study are not described, the reason for nonvisualization must be given. If all the required elements are not described nor reason for nonvisualization given, the exam would be considered a limited study, and the limited OB ultrasound code should be assigned (76815).

The following is a summary of the changes made:

Most significant of the radiology CPT® coding changes for 2003 were the revision of the pelvic ultrasound section and the provision of detailed guidelines for the use of the new and revised obstetrical ultrasound codes.

The American College of Radiology, in conjunction with a number of other specialty societies, formed a task force to develop a code describing a more detailed evaluation and measurement procedure for fetal characteristics. The task force also reviewed the obstetrical ultrasound codes and determined that revisions were needed, along with some new codes more in tune with recent advances in technology. The group recommended that the prior "Pelvic" ultrasound section be divided into "Obstetrical" and "Nonobstetrical" subsections, that five new codes (76801, 76802, 76811, 76812, and 76817) be added and that four code descriptors (76805, 76810, 76815, 76816) be revised. The CPT® Editorial Panel accepted the recommendations and established two new subheadings under the Diagnostic Ultrasound Pelvis section to differentiate between obstetrical and nonobstetrical codes.

Detailed introductory notes are provided in the CPT® 2003 Manual under the "obstetrical" ultrasound section. This section provides extensive comments on what should be included in each exam. Note that documentation must be provided in the radiology report that describes all the elements required for the study. If all the elements required for the study are not described, the reason for nonvisualization must be given. If all the required elements are not described nor reason for nonvisualization given, the exam would be considered a limited study, and the limited OB ultrasound code should be assigned (76815).

The following is a summary of the changes made:

Obstetrical Ultrasound

Codes 76801 (first fetus) and 76802 (each additional fetus) are used to describe fetal and maternal evaluation ultrasound procedures performed during the first trimester (<14 weeks 0 days) of pregnancy. These studies are performed to determine fetal viability, number of gestational sacs and fetuses, placental position and anatomy, qualitative assessment of amniotic fluid and gestational sac shape and each of these should be documented on images and in the report. Fetal anatomy appropriate for this stage of gestation is evaluated. Measurements vary depending on the size of the embryo or fetus in the various stages of the first trimester and may include crown rump length, gestational sac size, and head circumference. Examination of the maternal uterus and adnexa is included. With multiple gestations, use 76801 for the first gestation and +76802 for each additional gestation.

Revised codes 76805 (first fetus) and +76810 (each additional fetus) describe what previously was called a "complete" post-first-trimester obstetrical ultrasound that includes determination of fetal dates or size, typically with measurements of biparietal diameter, head circumference, femur length and abdominal circumference, evaluation of the placenta and amniotic fluid assessment; evaluation of fetal anatomy to include survey of intracranial, spinal and abdominal anatomy, four-chambered heart, and umbilical cord insertion; and evaluation of the maternal uterus and adnexa, when visible. The procedures include gray-scale, real-time imaging with image documentation and written interpretation of all described elements or reason for nonvisualization.

Codes 76811 (first fetus) and +76812 (each additional fetus) were added to describe a more extensive evaluation and detailed fetal anatomic examination for pregnancies at elevated risk for birth defects after the first trimester. It is important to note that all elements of a detailed fetal evaluation must be documented in the patient report. In addition to all the elements described above for 76805 and +76810, the elements of a detailed anatomic evaluation of the fetus include: the fetal brain, cerebral ventricles, face, heart (including outflow tracts), chest anatomy, organ-specific abdominal anatomy, number, length and architecture of limbs, and detailed evaluation of the umbilical cord and placenta. Reports should document the results of the evaluation of each of the elements described or reason for nonvisualization. With multiple gestations, it is appropriate to use 76811 for the first gestation and 76812 for each additional gestation.

The "limited" obstetrical code descriptor (76815) was revised to specify "one or more fetuses" and to distinguish this from the "follow-up" exam. This code is used for a selected, limited purpose such as evaluation of fetal viability, fetal position, or amniotic fluid check. It includes gray-scale, real-time images with written interpretation and, if possible, image documentation. Note that this code is to be used once per exam and not per element studied.

The CPT® 2003 manual notes that for the follow-up re-evaluation of fetal size and interval growth, or to re-evaluate one or more anatomic abnormalities previously noted on ultrasound, 76816 should be used per fetus. CPT® code 76816 includes fetal measurements as listed in the descriptor. If more than one fetus is evaluated, a –59 modifier should be appended to the additional 76816 code(s) to notify the carrier or third-party payer that this is a separate and distinct fetus studied and not a duplicate charge.

Note: Because modifiers are carrier-specific, you should contact your local Medicare carrier and other third-party payers for their guidelines and to verify that they are able to accept the recommended modifiers.

A transvaginal ultrasound of a pregnant uterus is now described by CPT® code 76817. The old transvaginal code 76830 is now used only for nonobstetrical applications. Typically 76817 is used in the first trimester but may also be used later in a pregnancy to evaluate cervical length and the position of the placenta relative to the internal cervical os. Radiologists should use 76817 in addition to the appropriate transabdominal code if both transabdominal and transvaginal studies are performed, as noted in the cross-reference following this code.

The parenthetical following the fetal biophysical profile codes (76818 and 76819) has been revised. Prior to 2003, the CPT® manual stated that modifier –51 (multiple procedure) should be used to designate the assessment of a second and any additional fetuses. However, to maintain uniform instruction within the CPT® coding system, the CPT® manual has been revised, and the instruction now recommends modifier –59 (separate study).

Nonobstetrical Ultrasound

A cross-reference has been added under the nonobstetrical transvaginal code (76830) to instruct the provider to use the appropriate transabdominal exam code in addition to the transvaginal code if a transabdominal exam is also performed. Because CPT® codes are created based on a substantial difference in the procedures performed, transvaginal studies are separated from transabdominal studies. This also allows studies to be tracked, e.g., in investigating how many ectopic pregnancies were discovered using transabdominal vs. transvaginal ultrasound.

Codes 76801 (first fetus) and 76802 (each additional fetus) are used to describe fetal and maternal evaluation ultrasound procedures performed during the first trimester (<14 weeks 0 days) of pregnancy. These studies are performed to determine fetal viability, number of gestational sacs and fetuses, placental position and anatomy, qualitative assessment of amniotic fluid and gestational sac shape and each of these should be documented on images and in the report. Fetal anatomy appropriate for this stage of gestation is evaluated. Measurements vary depending on the size of the embryo or fetus in the various stages of the first trimester and may include crown rump length, gestational sac size, and head circumference. Examination of the maternal uterus and adnexa is included. With multiple gestations, use 76801 for the first gestation and +76802 for each additional gestation.

Revised codes 76805 (first fetus) and +76810 (each additional fetus) describe what previously was called a "complete" post-first-trimester obstetrical ultrasound that includes determination of fetal dates or size, typically with measurements of biparietal diameter, head circumference, femur length and abdominal circumference, evaluation of the placenta and amniotic fluid assessment; evaluation of fetal anatomy to include survey of intracranial, spinal and abdominal anatomy, four-chambered heart, and umbilical cord insertion; and evaluation of the maternal uterus and adnexa, when visible. The procedures include gray-scale, real-time imaging with image documentation and written interpretation of all described elements or reason for nonvisualization.

Codes 76811 (first fetus) and +76812 (each additional fetus) were added to describe a more extensive evaluation and detailed fetal anatomic examination for pregnancies at elevated risk for birth defects after the first trimester. It is important to note that all elements of a detailed fetal evaluation must be documented in the patient report. In addition to all the elements described above for 76805 and +76810, the elements of a detailed anatomic evaluation of the fetus include: the fetal brain, cerebral ventricles, face, heart (including outflow tracts), chest anatomy, organ-specific abdominal anatomy, number, length and architecture of limbs, and detailed evaluation of the umbilical cord and placenta. Reports should document the results of the evaluation of each of the elements described or reason for nonvisualization. With multiple gestations, it is appropriate to use 76811 for the first gestation and 76812 for each additional gestation.

The "limited" obstetrical code descriptor (76815) was revised to specify "one or more fetuses" and to distinguish this from the "follow-up" exam. This code is used for a selected, limited purpose such as evaluation of fetal viability, fetal position, or amniotic fluid check. It includes gray-scale, real-time images with written interpretation and, if possible, image documentation. Note that this code is to be used once per exam and not per element studied.

The CPT® 2003 manual notes that for the follow-up re-evaluation of fetal size and interval growth, or to re-evaluate one or more anatomic abnormalities previously noted on ultrasound, 76816 should be used per fetus. CPT® code 76816 includes fetal measurements as listed in the descriptor. If more than one fetus is evaluated, a –59 modifier should be appended to the additional 76816 code(s) to notify the carrier or third-party payer that this is a separate and distinct fetus studied and not a duplicate charge.

Note: Because modifiers are carrier-specific, you should contact your local Medicare carrier and other third-party payers for their guidelines and to verify that they are able to accept the recommended modifiers.

A transvaginal ultrasound of a pregnant uterus is now described by CPT® code 76817. The old transvaginal code 76830 is now used only for nonobstetrical applications. Typically 76817 is used in the first trimester but may also be used later in a pregnancy to evaluate cervical length and the position of the placenta relative to the internal cervical os. Radiologists should use 76817 in addition to the appropriate transabdominal code if both transabdominal and transvaginal studies are performed, as noted in the cross-reference following this code.

The parenthetical following the fetal biophysical profile codes (76818 and 76819) has been revised. Prior to 2003, the CPT® manual stated that modifier –51 (multiple procedure) should be used to designate the assessment of a second and any additional fetuses. However, to maintain uniform instruction within the CPT® coding system, the CPT® manual has been revised, and the instruction now recommends modifier –59 (separate study).

Nonobstetrical Ultrasound

A cross-reference has been added under the nonobstetrical transvaginal code (76830) to instruct the provider to use the appropriate transabdominal exam code in addition to the transvaginal code if a transabdominal exam is also performed. Because CPT® codes are created based on a substantial difference in the procedures performed, transvaginal studies are separated from transabdominal studies. This also allows studies to be tracked, e.g., in investigating how many ectopic pregnancies were discovered using transabdominal vs. transvaginal ultrasound.