CPT codes are the standardized language used by healthcare providers to describe medical procedures for billing purposes. This system ensures consistent communication with insurance companies and accurate reimbursement. For fetal and maternal ultrasound evaluations, specific CPT codes differentiate the type, timing, and complexity of the examination, clarifying the services rendered during prenatal care.
Primary Codes for Routine Obstetrical Ultrasounds
Routine obstetrical ultrasounds are covered by two main CPT codes, determined by the stage of pregnancy. Code 76801 is used for fetal and maternal evaluations performed before 14 weeks of gestation. This early scan confirms pregnancy, determines gestational age, assesses fetal viability, and surveys visible structures.
Code 76805 is the primary code for the standard, comprehensive second or third-trimester anatomy scan, performed after 14 weeks. This detailed examination includes a full evaluation of fetal anatomy, biometry, and maternal structures.
The 76805 examination requires documentation of measurements like the biparietal diameter (BPD), head circumference, femur length, and abdominal circumference to estimate fetal growth. It also includes a survey of the fetal head, chest, abdomen, spine, and extremities. The report must document placental location, its relationship to the cervix, and an assessment of the amniotic fluid volume. Maternal anatomy, including the uterus and adnexa, must also be surveyed.
Detailed and Targeted Fetal Evaluations
When a complication is suspected or a patient is high-risk, a more complex diagnostic study is required. CPT code 76811 is reserved for a detailed fetal anatomic examination of a single fetus, which goes far beyond the requirements of a routine scan. This examination is intended for pregnancies with a known or suspected fetal anomaly, such as those involving maternal diabetes or an abnormal prenatal screen.
This detailed study adds an extensive, in-depth review of specific fetal anatomical structures. For instance, the evaluation of the fetal heart is more comprehensive, and there is a detailed examination of the intracranial anatomy, face, and extremities. The goal of this targeted examination is to fully characterize any suspected abnormalities.
Follow-up ultrasounds conducted after a detailed examination should be reported with a different code to reflect a re-evaluation rather than a repeat of the full detailed study.
Understanding Limited Versus Complete Studies
The distinction between a “complete” and a “limited” study relates directly to the scope of the examination performed. A complete study, such as the routine anatomy scan (76805), requires a full, documented evaluation of all specified fetal and maternal structures. A limited study is a focused examination designed to answer one or a few specific clinical questions.
CPT code 76815 is used for a limited obstetrical ultrasound. This typically includes only one or a few components, checking the fetal heart rate, placental location, fetal position, or amniotic fluid volume. This code is appropriate for quick checks or when a full anatomical survey is not medically necessary.
For follow-up examinations that require more than a limited check but less than a complete survey, CPT code 76816 is used. This code covers studies like re-evaluating fetal size by measuring growth parameters or re-examining an organ system previously found to be abnormal. Code 76817 is specifically for an obstetric transvaginal ultrasound, often used to measure cervical length or obtain clearer images in early pregnancy.
Billing Nuances: Multiples and Modifiers
Coding for multiple gestations, such as twins or triplets, involves using add-on codes to account for the extra work required to examine each fetus. For a routine examination after the first trimester, 76805 is used for the first fetus, and the add-on code 76810 is listed separately for each additional fetus. Similarly, for a detailed exam, 76811 covers the first fetus, and 76812 is used for each subsequent fetus.
These add-on codes ensure that the healthcare provider is reimbursed for the increased time and resources necessary to perform a complete evaluation on every fetus in a multiple pregnancy. The reimbursement structure recognizes that examining a second fetus is a distinct, additional procedure.
Professional and Technical Components
The concept of a global procedure, which includes both the performance of the ultrasound and the interpretation of the images, is often separated into two components using modifiers. Modifier 26, known as the Professional Component, is appended to the CPT code when the service being billed is only the physician’s interpretation, supervision, and written report.
Modifier TC, the Technical Component, is used when the service being billed is only for the equipment, supplies, and the technician’s time used to acquire the images. This split billing is common when the ultrasound is performed at one location, like a hospital, but the images are sent to a separate radiologist’s office for interpretation.
The facility bills for the technical component (TC), and the interpreting physician bills for the professional component (26). Applying these modifiers correctly is necessary for accurate claim processing and prevents an insurance company from denying the claim as a duplicate service.