Question: For an ultrasound, the radiologist documented measurements of the uterus, endometrial complex, and ovaries. She noted no evidence of intrauterine pregnancy, no free fluid in the cul-de-sac, physiologic follicle formation, and positive Doppler flow in the ovaries. The patient had syncope but no confirmed pregnancy. Should I report an obstetric or nonobstetric ultrasound?
Answer: Because the patient has no confirmed pregnancy before the ultrasound, you should report a nonobstetric ultrasound.
The AMA’s CPT Assistant (October 2001) states that when a female patient presents with no confirmed pregnancy, you should report a nonobstetric ultrasound, regardless of whether the ultrasound confirms pregnancy.
On the flip side, if the patient had a confirmed pregnancy and presented for an ultrasound that might be pregnancy related, but the ultrasound does not demonstrate a pregnancy, you would report an obstetric ultrasound code.
ICD-9: Because you don’t have a confirmed diagnosis, you should report the symptom that led to the ultrasound: 780.2 (Syncope and collapse).
Related articles:
- New From CPT Assistant: Help with Trunk Ultrasound Coding Do you know exactly what’s in the mediastinum? Your US…
- Double Ultrasound Codes Spell Double Trouble With AuditorsAuthorities scrutinize medical necessity for 76830 & 76856. The OIG…
- Which Ultrasound Code Is Best for Bladder Volume? Question: A urologist wants to bill for an ultrasound…
