By: Stacy Chaplain, Director, Provider Education
Documentation requirements for obstetrical (OB) ultrasound under 14 weeks are frequently misunderstood. The final report determines whether a study is reported as a complete exam (76801) or a limited one (76815), and the distinction rests on what the radiologist documents.
What 76801 includes
CPT describes 76801 as an ultrasound of the pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach, single or first gestation.
In the introductory language for the obstetrical ultrasound codes, CPT guidelines indicate that 76801 includes:
- Determination of the number of gestational sacs and fetuses
- Gestational sac/fetal measurements appropriate for gestation
- Survey of visible fetal and placental anatomic structure
- Qualitative assessment of amniotic fluid volume/gestational sac shape
- Examination of the maternal uterus and adnexa
Findings or a reason, for every element
Radiologists should detail the findings for each element, or explain why they could not evaluate a specific structure. If the required information is missing from the report, the study defaults to a limited OB ultrasound code.
The challenge of early gestation
Many providers find this guideline frustrating because it is often too early in the pregnancy to assess structures such as the placenta or amniotic fluid. The coding guidance from the American College of Radiology (ACR) and the American Medical Association (AMA) is clear, however: the report must document the reason for non-visualization to meet the requirements for reporting 76801.
A brief statement is sufficient. Examples of supporting language include:
- “The placenta and amniotic fluid cannot be adequately visualized due to early gestational age.”
- “Placental evaluation is limited by early gestation.”
Bottom line
Clear, comprehensive documentation supports accurate coding of complete versus limited OB ultrasound examinations. Addressing each required element, or stating why an element could not be assessed, keeps the report aligned with the CPT criteria for 76801.
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