What is involved in Maternal/Fetal Ultrasound Coding

 

Let’s start at the beginning…

In the world of Obstetrics, Maternal Fetal Medicine (MFM)/Perinatology is a sub-specialty that is focused on the fetus, and it’s growth during the pregnancy.  Perinatology specialists work closely with obstetricians, and genetic counselors to provide care for high risk pregnancies, and to provide screening services for potential fetal anomalies prior to birth.  The perinatal period, is generally defined as the time from 8-12 weeks gestation to approximately 30-45 days after delivery.

MFM/perinatal specialists can provide extensive care for high risk pregnancies, to include such diagnoses as multiple gestation (twins, triplets etc) , in-vitro fertilization pregnancies, advanced maternal age,  and chronic maternal diagnoses (i.e. hypertension, diabetes) . Perinatologists can also perform and provide extensive ultrasound procedures with interpretation of fetal growth and/or anomalies, placenta location, amniotic fluid, and umbilical cord complications during the pregnancy.  They also can provide highly complex surgical fetal procedures performed in-utero.

Coding for obstetric ultrasound can be challenging.  CPT has specific guidelines for each ultrasound code, yet the documentation and interpretation of these codes can be difficult to figure out when looking at the actual documentation or interpretation of the scans. 

CPT has outlined the obstetrical codes within the code series  76801 through 76828.  Not only do these codes include traditional ultrasound, but also include fetal biophysical profiles, doppler velocimetry of the fetal umbilical and middle cerebral artery but also echocardiography of the fetus.

Many Perinatologists practice in their own office, and have their own ultrasound equipment.  If the scan is provided in the office setting,  a global ultrasound code would be billed.  However, in locations that a perinatologist is not readily available, patients will have the scans performed in an outpatient facility.  If that is the case, the facility will bill the ultrasound with a TC (technical component only) modifier.  The facility will forward the scans, to the perinatologist to provide an interpretation of the scan.  The perinatologist will only bill for the written report or interpretation of the scan by adding the 26 (interpretation only) modifier to the cpt code. 

Conquering the Ultrasound code-set

According to the guidelines in CPT all diagnostic ultrasounds require both a permanently recorded image and a final written report.  A coder needs to fully understand if they are billing and coding ultrasound scans as A) Global or complete scan; B)the recorded image or Technical component only, or C) the interpretation/documentation only of the ultrasound scan.

Below are more helpful hints to coding Obstetrical ultrasounds:

§    Review the code definitions to determine if the CPT code itself specifies for the first or single gestatation – such as found in code 76801

§    If the add-on code “Ì” symbol is denoted at the beginning of the CPT code, do not use a 51 modifier with the code, as per the CPT definitions of a ‘add on code’.  Review code 76802 to understand the add on code is used to denote ‘each additional gestation”   

§    If the CPT code set does not specify ‘units”   such as in the code 76815, it states 1 or more fetus’s so only 1 unit would be appropriate.  It should not be billed as 2 units. Only as 1 unit, even though more than 1 fetus may be documented.

§    If the CPT code set does not specify ‘units” as in code 76816, CPT informs the coder to add the modifier 59 for each additional fetus when reporting  If coding for twins, the codes reported would be 76816 for baby a, and 76816-59 for baby b.

§    Review codes carefully to determine if a trimester has been specified within the ultrasound codeset such as in code 76805

§    Review to determine if the ultrasound is performed trans-abdominally, or trans-vaginally. 

Deciphering the Terminology

In MFM/Perinatology medicine, there are many strange words and procedures, that a coder should understand before trying to decipher an ultrasound documentation.  Included below are terms commonly found in MEM/perinatology ultrasound documentations.

Term	Abbreviation	Definition
Amniocentesis	Amnio	A procedure to draw a sample of amniotic fluid which is then analyzed to detect chromosome abnormalities, structural defects and metabolic disorders.
Amniotic Fluid	Amnio Fluid	The fluid in which the embryo or fetus is suspended within the womb (the embryonic sac inside the uterus).
Beats per minute	bpm	the number of heartbeats per unit of time (beats per minute)
Chorionic Villus Sampling	CVS	An alternative to amniocentesis to detect chromosomal abnormalities. The CVS can be performed earlier in fetal development than amniocentesis, and thereby allows earlier diagnosis.
Congenital Defect		A problem or condition existing at or dating from birth; acquired during development in the womb (uterus) and not through heredity
Crown Rump Length	CRL	the ultrasound measurement of a fetus
Fetosocopy		A minimally-invasive examination of the fetus by a miniature video camera inserted through a small tube
Estimated Date of Confinement	EDC	a term for the estimated delivery date for a pregnant woman
Fetal Abnormality		A condition detected in the unborn human that is not the normal or average.
Fetal Echocardiography		A high resolution ultrasound test to detect heart abnormalities in the fetus.
Fetal Pole		a thickening on the margin of the yolk sac of a fetus during pregnancy
Genetic Counseling		Medical guidance concerning inherited (genetic) disorders.
In Utero		Relating to being in the womb
Intra-Uterine Pregancy	IUP	the normal location for a pregnancy to occu
In-vitro Fertilization	IVF	a process by which egg cells are fertilized by sperm outside the body
Last Menstrual Period	LMP	the first day of the menstrual period prior to conceiving, used to calculate Expected Date of Delivery
Magnetic Resonance Imaging	MRI	A noninvasive diagnostic technique that produces computerized images of internal body tissue induced by the application of radio waves
Maternal Fetal Medicine	MFM	The testing and management of high-risk pregnancies; also called perinatology
Neonatal Intensive Care Unit	NICU	An area within a hospital dedicated to the care and treatment of pre-term and   critically ill babies
Neural Tube Defect	NTD	an opening in the spinal cord or brain that occurs very early in human development, visualized by ultrasound
Nuchal Translucency	NT	The area around the neck of the fetus, also known as the nuchal fold
Postnatal		Occurring, existing or performed after birth
Prenatal		Occurring, existing or performed before birth
Trans-abdominal ultraound	TAUS	Ultrasound procedure performed to visualize the pelvic cavity through application of sound waves by a device placed upon the abdomen
Trans-Vaginal ultrasound	TVUS	Ultrasound procedure performed to visualize the cervix and uterine contents by application of sound waves through a device inserted into the vagina.
Trimester		the division of pregnancy into three-month sections
Ultrasound	U/sound	A technique involving the formation of a 2D-or 3D dimensional image used for the examination and measurement of bodily abnormalities.

What the documentation reports look like

Included below is a dictation that shows the correct coding and documentation for a twin pregnancy.  Review and test yourself on the codes to be applied.  This documentation was performed as a global procedure in the perinatologists office

ULTRASOUND EXAMINATION:

The LMP of this 30 year old, G1, P0-0-0-0 patient was unknown, her working

EDC is MAR 8 2011 and the current gestational age is 11 weeks 2 day(s) by

date of assisted reproductive procedure. A sonographic examination was

performed on AUG 19 2010.

A normal gestational sac was documented. The yolk sac was seen, measuring

0.4 cm. The amnion was also documented. A normal fetal pole was noted with

cardiac motion at 169 bpm.

EXAM INDICATIONS:

1) 1st Trimester Screening    2) Twins    3) IVF

CPT Coding: 76801   +76802

Diagnosis Code(s)  651.03

***************************************************************************

FETUS A EXAMINATION:

GENERAL RESULTS:

Fetus # 1 of 2

Variable presentation

Fetal growth appeared normal

Placenta Location = Posterior

No placenta previa

Placenta Grade = 0

Amniotic Fluid = Normal

FETAL MEASUREMENTS:

* Indicates Measurement Included In Average Gestational Age

CRL 4.5 cm c/w 11 weeks 1 day(s)*

THE AVERAGE GESTATIONAL AGE is 11 weeks 1 day(s) +/- 7 days.

ANATOMY DETAILS:

Visualized, Appearing Sonographically Normal:

STOMACH, BLADDER, PLACENTA

Suboptimal:

RIGHT KIDNEY, LEFT KIDNEY

UTERUS/ADNEXA

The uterus was visualized, midplane in orientation.

IMPRESSION:

Twin IUP (Fetus A)

11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8

2011)

11 weeks 1 day(s) by this ultrasound. (EDC= MAR 9 2011)

Variable presentation

Fetal growth appeared normal

Chorionicity = Dichorionic, Diamniotic

RECOMMENDATIONS:

Repeat ultrasound in one week.

****************************************************************************

FETUS B EXAMINATION:

GENERAL RESULTS:

Fetus # 2 of 2

Fetal growth appeared normal

Placenta Location = Posterior

No placenta previa

Placenta Grade = 0

Amniotic Fluid = Normal

FETAL MEASUREMENTS:

* Indicates Measurement Included In Average Gestational Age

CRL 5.2 cm c/w 11 weeks 5 day(s)*

THE AVERAGE GESTATIONAL AGE is 11 weeks 5 day(s) +/- 7 days.

ANATOMY DETAILS:

Visualized, Appearing Sonographically Normal:

STOMACH, BLADDER, PLACENTA

Suboptimal:

RIGHT KIDNEY, LEFT KIDNEY

UTERUS/ADNEXA

The uterus was visualized, midplane in orientation. The left ovary was

enlarged, measuring 7.6 x 5.9 x 7.0 cm. The right ovary was enlarged,

measuring 6.1 x 5.5 x 4.0 cm.

IMPRESSION:

Twin IUP (Fetus B)

11 weeks 2 day(s) by date of assisted reproductive procedure. (EDC= MAR 8

2011)

11 weeks 5 day(s) by this ultrasound. (EDC= MAR 5 2011)

Fetal growth appeared normal

Chorionicity = Dichorionic, Diamniotic

RECOMMENDATIONS: COMMENTS:

Patient is seen for first trimester screening.

The CRL is at the lower limits for the NT measurement and it could not be obtained on either twin given patient habitus. Thus patient will need to return for the serum screen and NT measurement. Sequential screening was discussed in detail with regard to the 2 step testing process. Screening for a NTD is only provided when the second serum screen is completed. Cystic fibrosis screening was also discussed. At the conclusion of the discussion, patient wished to return for the NT and serum screen.

Repeat ultrasound in one week.

CPT	Diagnosis
76801	651.03 V28.3
+76802