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).
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