I know that in order to bill a complete pelvic ultrasound the measurement of the uterus, adnexal structures, endometrium, and any pelvic pathology must have been assessed and documented, but do both ovaries have to be documented?

For example, the doctor says the left ovary could not be well seen and lists what he saw on the right ovary as well as the uterus and endometrium measurements. Can a pelvic complete be charged?


Ovaries are part of the adnexa, so both must be documented. If the doctor cannot see one or both, he must state why he could not see. If the attempt was made to view the right ovary but it could not be seen or not seen well, and the documentation says the reason it could not be seen, then you can “count” the right ovary. If the doctor just says “right ovary not seen” or “right ovary not seen well,” then it does not count, and a limited exam must be reported.


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.