Coding

  • 1.  76816

    Posted 01-21-2024 11:20

    Hi,

    For a follow up growth ultrasound (76816), do we have to report Maternal Structures if the previous ultrasounds, did not report any abnormities?  



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    Michael Pinette
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  • 2.  RE: 76816

    Posted 01-21-2024 17:46
    76816 requires assessment of anatomy OR growth. So you use the code to follow-up on anatomy that couldn't be seen on a prior 76805/76811 or you could use it to assess growth. That is sort of the minimum. I think best practice would be that a follow-up should include biometry if > 2–3 weeks from a prior study with biometry, and it should include anatomy that could change during the course of pregnancy despite appearing normal previously (eg, lateral cerebral ventricles, 4-chamber view, diaphragm, bowel, kidneys). We also always document presentation, placental location and fluid on our follow-ups at the University of Vermont, but it isn't strictly required by the CPT code.




    Best regards,


    David C Jones, MD
    Director, University of Vermont Medical Center Fetal Diagnostic Center
    Professor, Obstetrics, Gynecology & Reproductive Sciences
    University of Vermont
    Dept of Obstetrics, Gynecology & Reproductive Sciences
    Division of Maternal-Fetal Medicine
    (802) 847-5698



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  • 3.  RE: 76816

    Posted 01-21-2024 18:28

    Thank you Michael and David for this important discussion! 

    CPT 76816 does not require reporting on maternal structures. It requires follow up fetal anatomy and/OR growth.
    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), trans-abdominal approach, per fetus
    See links below for components and reference. 
    Let us know if you have any further questions! Thank you. 



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    Steve Rad, MD, FACOG
    Chair, SMFM Coding Committee
    Los Angeles, CA
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  • 4.  RE: 76816

    Posted 01-22-2024 00:00

    Hello Michael,

    76816 CPT description states: Ultrasound, pregnant uterus, real time with image documentation, follow up (e.g., 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), trans abdominal approach per fetus.

    So looking at just one organ system is appropriate for 76816 when an indication is present. 

    Fadi



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    Fadi Bsat, MD, FAIUM
    Chair, SMFM Practice Management Committee
    Past Chair, SMFM Coding Committee
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