If we performed a complete obstetric ultrasound examination (code 76805) but were unable to see a handful of structures and had the patient come back to re-evaluate the fetal anatomy not seen well in the previous study, is the follow-up study reported as a limited evaluation (code 76815) or a reevaluation (code 76816) study?


The appropriate code to report for the re-evaluation of fetal anatomy not visualized well on a previous obstetrical ultrasound is code 76816, 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 an organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus. This code is designed to reassess fetal size and interval growth or to reevaluate one or more anatomic abnormalities of a fetus previously identified on an ultrasound. This code should be used once for each fetus. In a multiple pregnancy, modifier 59, Distinct Procedural Service, may be appended for each additional fetus reevaluated. (Source: Clinical Examples in Radiology, Volume 8, Issue 3; Summer 2012).

This question was answered in an edition of our Radiology Compliance Manager. For more hot topics relating to radiology services, please visit our store or call us at 1.800.252.1578, ext. 2.


CPT® copyright 2021 American Medical Association (AMA). All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.