What must be included in the report to determine the difference between fetal biophysical profile codes 76818 and 76819?
An article in the American College of Radiology (ACR) Radiology Coding Source March-April 2007, “Obstetrical Ultrasound Coding and the Radiology Report” said that reporting of the score (e.g., 8/8) ”satisfies the required documentation of the study being performed.” However, a Documentation Challenge in Clinical Examples in Radiology, Summer 2014 included a report that gave the score without any other documentation support for the score. The discussion in the article noted that “Fetal biophysical profile codes 76818 and 76819 include the assessment of the amniotic fluid and fetal breathing movements, tone, and gross body movement. The report does not document fetal breathing movement, tone, or trunk and extremity movement. Therefore, it is not appropriate to report either one of these codes.” Based on this more recent article from the American Medical Association (AMA) and ACR, while the report should document the score, it should also document the elements evaluated to get the score.