Better Clinical Documentation = Better Coding, Better Reimbursement for OB ultrasound

Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA, CDIP

With the uncertainty of ICD-10 implementation, rather than focus on ICD-10 cm diagnosis coding, the educational focus is now shifting to overall better clinical documentation of patient care. OB ultrasound is used in both private practice and in the hospital inpatient and outpatient setting. The three most common OB ultrasounds billed in the office and outpatient areas are

• 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
  
• 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), transabdominal approach, per fetus
  
• 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal

A provider needs to be well versed in the criteria needed for documenting, and coding for these very commonly performed ultrasounds. According to ACOG (American Congress of Obstetricians and Gynecologists) ultrasound is not considered “bundled” into an ob package. Therefore, providers can and should be billing for ultrasound as a separately identifiable procedure. If you are going to bill for an ultrasound, there has to be:

• a permanently recorded image
• a final written report.

If there is not a permanently recorded image, then an ultrasound cannot be billed. Ultrasound codes are billed based upon the technical component and the interpretation being done as a “global” or “combined” procedure billed as 1 code. However, if the technical component is billed by a facility (eg CPT code 76815-TC) it should be billed with the date it was performed. If the interpretation is performed a few days later, then the billing of that separate piece of the procedure should be billed with the date of the actual “interpretation”… yet there should be an annotation stating the procedure was performed on 01.01.2014, and the interpretation was performed on 01.02.2014. By following this guidelines, the documentation now provides good clear separation of the technical component and who performed it, and of the interpretation (eg findings) of the scan and who performed that piece of the procedure.

An ultrasound has three components that make up appropriate billing of an ultrasound code. All three of these functions must be documented within the medical record. If they are not documented, then ask the provider to document prior to billing.

1) The Pre-service work:

1. Chart Review of prior clinical information
2. Review of pertinent prior imaging studies
3. Proper Draping & Positioning of the Patient

2) The Intra-Service work (eg. thework involved in performing the actual Scan)

• The physical performance of the scan by the provider or sonographer
• If performed by a sonographer – Supervision of the sonography
• Standard Clinical work detail criteria noted (Key elements) and of the actual scan findings
• Interpretation and preparation of the report for the Permanent Medical Record (electronic or paper)

3) The Post Service Work

• Discuss the findings with the patient and referring physician (when appropriate)
• Review and Sign the permanent record/prepared report

Let’s take a look at clinical documentation for the codes themselves

76815 Quick Peek
Definition: Ultrasound, pregnant uterus, real time with image documentation, limited

• fetal heart beat,
• placental location,
• fetal position and/or qualitative amniotic fluid volume,
• 1 or more fetuses

Diagnosis: “Suspected” or “Confirmed” anomaly, Sign, Symptom, or problem…


76816 Ultrasound
Definition: pregnant uterus, real time with image documentation
follow-up / eg, re-evaluation of fetal size

• measuring standard growth parameters and amniotic fluid volume, (to include if appropriate, BPD (Bi-Parietal Diameter), AC abdominal circumference, FL femur length, HC Head Circumference or other appropriate measurement
  
• re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan) and may include comparison of this examination to a prior study to evaluate the interval change (i.e. fetal growth)
  
• transabdominal approach, per fetus

Diagnosis: “Suspected” or “Confirmed” anomaly, Sign, Symptom, or problem…

76817 Ultrasound,
Definition: pregnant uterus, real time with image documentation, transvaginal

• Evaluation of embryo(s) and gestational sac(s)
• Evaluation of maternal uterus, adnexa and/or cervix to include evaluation of characteristics of the cervix including length and structure
• Evaluation of the fetus and placenta

Diagnosis: “Suspected” or “Confirmed” anomaly, Sign, Symptom, or problem…


Let’s take a look at sample dictated clinical documentation interpretation reports

76816: Clinical example dictation interpretation report:

EXAM: OB follow up Ultrasound.

HISTORY: Follow up U/S for possible IUGR .(growth). Patient with IUGR in previous pregnancy.

FINDINGS: A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute. Placenta is located posteriorly, grade 0 without previa. Cervical length is 4.2 cm. There is normal amniotic fluid index of 12.2 cm. There is a 4-chamber heart. There is spontaneous body/limb motion. The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.

BIOMETRIC DATA:
BPD = 7.77 cm = 31 weeks, 1 day
HC = 28.26 cm = 31 weeks, 1 day
AC = 26.63 cm = 30 weeks, 5 days
FL = 6.06 cm = 31 weeks, 4 days

Composite sonographic age 30 weeks 6 days plus minus 17 days.

Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.

IMPRESSION: Single live intrauterine gestation without complications. Growth is noted as normal, no IUGR at this time
Diagnosis:
ICD-9 = 655.83 (Known or suspected fetal anomly NEC)
ICD-10cm = ICD-10-CM O35.8XX0


76815 Clinical example dictation interpretation report:

Patient is 24 y.o. G3P2002 at 32+1 weeks with severe oligohydramnios. She was hospitalized late yesterday afternoon for severe oligohydamnios noted on routine US follow up. Fetal growth was appropriate although the BPD was <5 2="" 5l="" 6="" and="" at="" babies="" been="" br="" contracting.="" decelerations.="" dr="" fetal="" for="" has="" hc="" her="" history="" hydration="" ile.="" ile="" is="" iugr="" ivf="" monitoring="" no="" not="" overnight="" per="" prior="" reactive="" received="" she="" significant="" term.="" with="" zzz="">
AFI this am is 4.2 and there is a 2x2cm pocket.
UA doppler is normal.
Fetus is breech.
Estimated Fetal Weight yesterday was 1676g.
A/P:: SEVERE OLIGO AT 32 weeks despite aggressive IV fluid hydration.
-Given no significant improvement, will discontinue IV fluids.
-Discussed recommendation for continued in house surveillance, monitoring with repeat AFI on 6/19 with patient. Will monitor fetus for 2 hrs tid and longer if indicated. She will receive her 2nd dose of betamethasone tonight.

Diagnosis: ICD-9 = 658.03 Oligohydamnios ICD-10cm = O41.03X0

Note - This u/sound is billed as a 76815-26 as this was an interpretation only, as the hospital will bill for the technical component for usage of the ultrasound.


76817 Clinical example dictation Interpretation report. 

The LMP of this 20 year old, gravida 2, para 0 patient was FEB 4 2014,giving her an EDD of NOV 11 2014 and a current gestational age of 21 weeks3 days by dates. A sonographic examination was performed on JUL 4 2014 using real time equipment.
Regular fetal heart rate was observed at 140 bpm.

CERVICAL EVALUATION
The cervix appeared abnormal.
Supine
Cervical Length: 0.60 cm Funnel Length: 3.90 cm
Funnel Width: 1.70 cm
Percent Funneling: 86.67%
Post Trans Fundal Pressure
Cervical Length: 0.60 cm Funnel Length: 3.90 cm
Funnel Width: 1.70 cm
Percent Funneling: 86.67%
Other Test Results
Funneling?: Yes Dynamic Changes?: No
Resp To Valsalva: No

IMPRESSION
Singleton IUP 21 weeks and 3 days by dates. (EDD=NOV 11 2014)

RECOMMENDATION
Ultrasound: Within 3-4 Days

Narrative Description:
Patient evaluated in L/D. Transvaginal Ultrasound performed by my self.
Yiledent large funnel with intact cervical length of 5-6 mm. No change with Valsalva.

COMMENT/DISCUSSION : Detailed discussion was had regarding real time bedside transvaginal ultrasound findings regarding short cervical length. Explained without history of preterm birth that short cervix alone highly correlates for risk of preterm delivery before 32 weeks based on the literature. We discussed the many possible causes including intraamniotic infection, anatomical variation, preterm contractions , cervical insufficiency or multiple pathologic processes occurring at the same time. We discussed that a short cervix at this gestational age( less than 15 mm) has been shown to benefit form vaginal progesterone. We discussed operative procedure of performing a cerclage after ruling out infection however literature supports the progesterone since she has not had a prior PTD Explained to patient that if + amnio for infection that delivery is indicated regardless of gestational age, regardless of viability status.
Diagnosis = Short Cervical Length Antepartum
ICD-9 = 649.73 ICD-10cm = O26.872
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As you will notice all of these documentation samples include the plan of care, as the provider has noted this on the ultrasound reports. However, if the provider is simply doing an ultrasound and not providing out the "complete" care of the patient, then only the ultrasound clinical information will be needed on the official interpretation report.

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP  and ICD10 cm/pcs Ambassador/trainer is an E&M, and Procedure based Coding, Compliance, Data Charge entry and HIPAA Privacy specialist, with over 20 years of experience. Lori-Lynne’s coding specialty is OB/GYN office & Hospitalist Services, Maternal Fetal Medicine, OB/GYN Oncology, Urology, and general surgical coding. She can be reached via e-mail at webbservices.lori@gmail.com or you can also find current coding information on her blog site: http://lori-lynnescodingcoachblog.blogspot.com/.