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Basics about Pelvic Ultrasound CPT code 76856

In Radiology, diagnosis related to pelvic region are very common to code. For example, for ovary cyst, pelvic pain, abdominal pain etc. are the common diagnosis for Pelvic exam in females. Mostly the ultrasound CPT code 76856 is used for pelvic region. This is the most frequently used Ultrasound CPT code in Radiology. Also, along with CPT 76856, we will be mostly coding endovaginal CPT code 76830. Both these codes are coded together in most of the exam. But, medical coders should carefully read the documentation and then only code for Pelvic ultrasound (76856) and Endovaginal (76830) cpt codes. If the exam or the technique does not support any of these CPT codes, we should not assign these codes.

76856 – Pelvis, non-OB Ultrasound Complete Transabdominal Exam

76857– Pelvis, non-OB Ultrasound Limited Exam

CPT code 76856 & 76830, should be used only for Non-OB exam, for OB or pregnancy exam, biophysical profile exam we have separate CPT codes.

CPT code 76856 is a complete evaluation and must minimally include:

Female: description and measurements of the uterus and adnexal structures, measurement of the endometrium and bladder, and a description of any pelvic pathology.
Male: evaluation and measurement of the bladder, evaluation of the prostate and seminal vesicles and any pelvic pathology.

CPT code 76857 is a limited study and typically focuses on one or more elements listed under 76856 and/or the reevaluation of one or more pelvic abnormalities

Definitions

Transvaginal Ultrasound: A transvaginal ultrasound is a type of pelvic ultrasound used by doctors to examine female reproductive organs. This includes the uterus, fallopian tubes, ovaries, cervix, and vagina. “Transvaginal” means “through the vagina.” This is an internal examination.
Pelvic Ultrasound: A pelvic ultrasound is a noninvasive diagnostic exam that produces images that are used to assess organs and structures within the female pelvis. A pelvic ultrasound allows quick visualization of the female pelvic organs and structures including the uterus, cervix, vagina, fallopian tubes and ovaries. The transducer is pressed firmly against the skin and swept back and forth over the lower abdomen and images are obtained of the uterus, ovaries, and surrounding pelvic structures. This is an external examination.

Non-Obstetrical: Not related to the pregnancy, child birth nor postpartum period.

When to use CPT code 76856 & 76830

There are two CPT codes for coding Pelvic Ultrasound, procedure code 76856 and 76857. Now, when all the pelvic organs including the uterus, adnexal structures, ovaries, endometrium, bladder along with a pelvic diagnosis are present, you can go ahead and code CPT code 76856 (complete exam).

When only one organ or some of the region of pelvic is studied, we have to code a limited Pelvic ultrasound CPT code 76857. Hence, medical coders should read the medical report accurately to code between complete and limited ultrasound CPT code for pelvic region. And the Ultrasound CPT 76830 is used when the endovaginal exam is performed. Below are the details description of all these CPT codes.

76856 – Pelvis, non-OB Ultrasound Complete Transabdominal Exam

76857- Pelvis, non-OB Ultrasound Limited Exam

76830- Pelvis, non-OB Endovaginal Exam

Elements required for Coding CPT 76856

Non-OB Female Pelvic US
• Description AND measurements of the uterus and adnexal structures
• Measurement of the endometrium
• Measurement of the bladder (when applicable)
• Any pelvic pathology imaged

Male Pelvic US
• Evaluation and measurement (when applicable) of the urinary bladder
• Evaluation of the prostate and seminal vesicles (to the extent they are visualized
transabdominally)
• Any pelvic pathology imaged

FAQ

What is reimbursement rate, fees, pay or cost of CPT code 76856?

For checking the actual or updated fees, pay or cost for CPT code 76856, you have to visit the below link of medicare website.

https://www.cms.gov/medicare/physician-fee-schedule/search

Here you have to enter the CPT code you want to search in the HCPCS code box as shown below.

Once you have clicked search fees, you will get results as shown below. Reimbursement rate, fees, cost for facility, non-facility & region or locality wise you will get all information for CPT code 76856. Also you can get the modifier applicable for that CPT code as highlighted below.

can CPT code 76856 and 93975, 93976 be billed together?

For Checking the overlapping of any two or more CPT code you have to check the NCCI edits between the procedures codes. Below link will help to find any overlapping between two or more procedure or CPT code. But first you have know the about Modifier indicators 0,1 and 9.

https://www.cgsmedicare.com/medicare_dynamic/j15/ptpb/ptp/ptp.aspx

Modifier Indicator

0 Codes are always bundled; do not submit a modifier for exceptions

1 Exceptions may apply; submit the appropriate modifier. (Note: documentation is required in the patient’s medical record.)

9 Not applicable. The code pair is no longer bundled and no modifier is needed for purposes of noting an NCCI exception.

Now we will check the NCCI edit of CPT code 76856

First enter the CPT code you want to search in the search box as shown below.

Now click the search box to get the results

As per the above results, CPT code 76856 can be coded with 93976 together with the help of Modifier 59 or X- modifiers, since it has ‘0‘ as modifier indicator. While CPT code 76856 and 93975 are mutually exclusive procedures and it has ‘9’ as modifier indicator. Here, a modifier is assigned when both procedure are done on different anatomic site and if both procedure are done on same anatomic site, only the most comprehensive code with be reported.

Also, 93975 is a comprehensive CPT code while 76856 is a minor code, so when both have to be coded together then coders have assign 59 or X-modifiers to CPT code 76856 as per NCCI edit below.

Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ. But, if these procedures are performed on different site or different encounter, we can code them together using a 59 or X- modifier.

This way you can find does any overlap exist between any two procedure or CPT codes.

Points to remember while coding CPT code 76856 & 76830

As you know the, their are OB and Non-OB CPT codes for Pelvic exam, hence do not get confuse with these codes. The Pelvic ultrasound OB Cpt code include codes 76801,76802, 76805, 76810 etc. While the Non-OB Pelvic CPT codes include 76856, 76857 and 76830.

We can billed Procedure code 76856 & 76830 together. Many coders have confusion in billing these two codes together. But, as per coding guidelines their are no NCCI edits between CPT code 76856 & 76830, hence both procedure codes can be coded together. Exception can be for AETNA, which says Effective December 1, 2012, CPT Code 76856 (pelvic ultrasound) will deny as incidental when billed with 76830 (transvaginal ultrasound) on facility claims. Specialists are currently subject to this edit.

Do not code the complete (76856) and limited (76857) exam CPT codes together. Both exam cannot be done together.

Do not code a complete exam CPT code 76856 for limited exam. This is called Upcoding, because your charging more by coding high dollar value CPT code.

Do not code 76817 for non-OB procedure for transvaginal exam. CPT Code 76817 describes obstetrical ultrasound evaluation via the transvaginal approach and includes evaluation of embryo(s) and gestational sac(s) and evaluation of maternal uterus, adnexa, and/or cervix. CPT code 76830 is coded for N0n-OB Ultrasound transvaginal exam and code 76817 is used for coding OB or pregnant uterus.

Evaluation of anything less than the required elements for a complete nonobstetrical pelvic ultrasound is reported with code 76857 (eg, follow-up examination for ovarian follicles or evaluation of the urinary bladder alone). In radiology report, if all the required elements not described in the report (eg, missing documentation of the reason for nonvisualization of the left ovary), only the limited nonobstetrical code (CPT code 76857) may be reported. However, coders should ask the radiologist for further clarification to ensure accurate coding and to amend the report, as necessary.

Droperidol uses, brand name injection and its dose

Reimbursement

CPT code 76856 represents a non-obstetrical pelvic ultrasound, real time with image documentation; complete. CPT code 76830 represents a non-obstetrical transvaginal ultrasound. During the course of an office visit, if a provider performs a pelvic ultrasound and determines that the image is unclear and that a transvaginal ultrasound is necessary, only the transvaginal ultrasound will be reimbursed at 100% of the allowed amount. The pelvic ultrasound will be reimbursed at 50% of the allowed amount.

Coding Examples for 76856 & 76830 CPT codes

Scenario 1

Suppose a patient comes with a pelvic pain and the physician orders a pelvic transabdominal and transvaginal ultrasound. But, to code both procedures, documentation should clearly support the ordered exam.

If the medical report, only documents and talks about transabdominal pelvic ultrasound exam, then only report CPT code 76856.

Scenario 2

Suppose, a patient comes with a pelvic pain and the physician performs a Non-OB pelvic transabdominal and transvaginal ultrasound exam. But, during examination the physician accidently finds the patient is pregnant. Now, how we should report this scenario.

We should only code what has been performed, hence in this exam physician has performed a Non-OB exam, and hence coder should report CPT code 76856 & 76830 only.

Do not code this chart with OB CPT code 76801 and 76817, just because patient is pregnant. This will lead to upcoding.

Code the procedure which has been ordered and performed by the physician.

Scenario 3

Now, if the patient has some OB pelvic pain and the physician performs an OB pelvic complete ultrasound both transabdominal and transvaginal.

Now, here if the documentation supports the procedures, the coder can directly report the OB procedure code 76801 for first trimester & 76805 for second and third trimester. Use CPT code 76817 for OB transvaginal ultrasound.

Do checkout the whether the exam performed is complete or limited. For limited OB exam the coder should report CPT code 76815.

Scenario 4

Suppose the patient has pelvic OB pain. This patient is 20 weeks pregnant with 2 fetuses. For twin pregnancy, the physician orders a complete transabdominal and transvaginal ultrasound exam.

Now, for this scenario if the documentation supports completely, the coder should report CPT code 76805 (first fetus) ,76810 (additional fetus) & 76817 for tansvaginal ultrasound exam.

For limited OB transabdominal exam, only one CPT code 76815 should be reported irrespective of the number of fetus. This CPT code 76815 description says “Ultrasound, pregnant uterus, real time with image documentation, limited, 1 or more fetuses“, hence we can report this code for multiple fetuses.

ICD 10 codes supporting CPT code 76856 & 76857

A18.14 Tuberculosis of prostate
A56.11 Chlamydial female pelvic inflammatory disease

N82.8 Other female genital tract fistulae
N83.53 – N84.0 – Opens in a new window Torsion of ovary, ovarian pedicle and fallopian tube – Polyp of corpus uteri

K68.11 Postprocedural retroperitoneal abscess
K68.9 Other disorders of retroperitoneum

N13.9 Obstructive and reflux uropathy, unspecified
N21.0 Calculus in bladder

Sample Coded report for Procedure code 76856 & 76830

EXAM: SAT SONO PELVIC W ENDOVAGINAL

REASON FOR STUDY: H/o: neoplasm, Cyst of ovary

CLINICAL HISTORY: History of fibroids and ovarian cysts.

TECHNIQUE:
The study was performed in an ACR accredited facility. A sonogram of the pelvis was performed utilizing transabdominal and transvaginal approaches assessing gray-scale appearance.

FINDINGS:
Uterus: The uterus measures 9.2 x 6.0 x 6.6 cm. There are numerous predominately intramural rounded regions of altered echotexture compatible with fibroids the largest noted within the posterior uterine body measuring 3.6 x 2.6 x 2.8 cm appreciably unchanged when compared to patient’s prior study. Endometrium: The endometrium is heterogeneous in echotexture measuring 3 cm. Ovaries: The right ovary measures 2.4 cm in the left ovary measures 6.4 cm. Within bilateral ovaries there are smoothly marginated round anechoic foci with imperceptible walls and increased through transmission compatible with simple cysts measuring 1.7 cm on the right and 5.5 cm on the left, previously measuring 7.7 cm on the patient’s October 2016 sonogram.
Free Fluid: None.

IMPRESSION:
1. Thickened heterogeneous endometrium measuring 3 cm. Endometrial lesion cannot be definitively excluded.
2. Stable uterine fibroids measuring up to 3.6 cm in size.
3. Bilateral ovarian cysts measuring up to 1.7 cm on the right and 5.5 cm on the left.