A fetal ultrasound or sonogram is a test that uses high-frequency sound waves to produce images of the developing baby in the uterus. This fetal imaging tool can accurately determine gestational age, fetal number, viability, and placental location. It is used to monitor fetal health and development, detect any congenital abnormalities or other potential problems, and help confirm a diagnosis. Ultrasound is an important component of obstetrics medical billing and physicians need to report services correctly to ensure accurate reimbursement.

Ultrasound Exams in Pregnancy

Ultrasounds allow obstetricians/gynecologists to study certain fetal structures. This allows them to evaluate the fetus’s well being as well as diagnose potential problems. While fetal abnormalities are generally rare, the American College of Radiology and the American Institute of Ultrasound in Medicine recommend that the following structures should be evaluated for defects during a routine prenatal ultrasound:

  • The chambers within the brain, distance between parietal bones of the fetal head and skin thickness at the back of head
  • The chambers and valves of the heart
  • The size, location, and arrangement of stomach and diaphragm
  • The size and presence of the urinary bladder
  • Spine
  • Umbilical cord
  • Presence and position of the kidneys
  • Limbs and other fetal parts

The first fetal ultrasound is typically performed during the first trimester to confirm the pregnancy and estimate the length of the pregnancy. In the case of an uncomplicated pregnancy, this may be followed by another ultrasound during the second trimester, when anatomic details are visible. A follow-up ultrasound or additional imaging tests, such as an MRI, might be recommended if a problem is suspected (Mayo Clinic).

Types of Fetal Ultrasound Exams

There are three types of prenatal ultrasound exams: standard, limited, and specialized

  • A standard ultrasound is performed at 18-22 weeks of pregnancy. It checks the fetus’s physical development, screens for major congenital anomalies, and determines gestational age and a due date. It can also provide information about the fetus’s position, movement, breathing, and heart rate; fetus size and weight; amount of amniotic fluid in the uterus; placenta location, and number of fetuses.
  • A limited ultrasound exam is done to check a specific problem such as the fetus’s position in the uterus when the mother is in labor.
  • A specialized ultrasound exam if a problem is suspected based on risk factors or other tests, for example to check the fetus’s growth rate if there are signs that the fetus is not developing properly.

Prenatal Ultrasound Options

There are two ways to conduct prenatal ultrasound exams: Transabdominal and Transvaginal.

  • Transabdominal ultrasound (TAU) is done by moving a transducer over the abdomen. This noninvasive option provides a wide view of the abdomen and pelvis. It requires a full bladder for optimal visualization of pelvic structures.
  • Transvaginal ultrasound (TVU) involves the insertion of a probe into the vagina. TVU provides a more limited pelvic view, but a better view of the uterus and adnexa during early pregnancy.

Advanced techniques such as 3-D ultrasound or 4-D ultrasound may be used when a more detailed image of the fetus and organs is required. Three-dimensional ultrasound provides a life-like image of the fetus, while a Doppler ultrasound helps to examine the movement of blood through the umbilical cord between the unborn baby and placenta. To validate a diagnosis, ultrasounds are usually combined with other tests such as triple tests, amniocentesis, or chorionic villus sampling.

Prenatal Ultrasound ICD-10 and CPT Codes 2020

Insurance companies pay for prenatal ultrasound services that are medically necessary. Anthem Blue Cross Blue Shield has published the prenatal ultrasound diagnosis codes effective from October 1, 2019 to September 30, 2020. The CPT codes for reporting prenatal ultrasound fall under Diagnostic Ultrasound Procedures of the Pelvis Obstetrical and are as follows:

  • 76801– Standard first trimester ultrasound: Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach
  • 76802-each additional gestation (List separately in addition to code for primary procedure)
  • 76805– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation
  • 76810– each additional gestation (List separately in addition to code for primary procedure performed)
  • 76811– Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
  • 76812– each additional gestation (List separately in addition to code for primary procedure)
  • 76815– Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position, and/or qualitative amniotic fluid volume), one or more fetuses
  • 76816– Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
  • 76817– Ultrasound, pregnant uterus, real time with image documentation, transvaginal

Knowing the distinct differences between these codes is necessary for accurate reporting. For instance, while both CPT 76805 and 76811 are for fetal and maternal ultrasound evaluation, 76811 includes a detailed fetal anatomic exam. An MDEdge article explains that the key to use of code 76811 is medical justification (such as a suspected fetal problem). Sophisticated ultrasound machines are necessary to perform a detailed exam.

MDEdge clarifies:

“Code 76811 (ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus a detailed fetal anatomic examination, transabdominal approach; single or first gestation) requires both basic examination of fetal and maternal structures included with code 76805 (determination of number of fetuses and amniotic/chorionic sacs; measurements appropriate for gestational age; survey of intracranial, spinal, and abdominal anatomy; 4-chambered heart; umbilical cord insertion site; placenta location; amniotic fluid assessment; and maternal adnexa), and a detailed examination of fetal anatomy. This includes evaluation of fetal brain and ventricles; face; heart and outflow tracts and chest anatomy; abdominal organ-specific anatomy; number, length, and architecture of limbs; and detailed evaluation of the umbilical cord, placenta, and other fetal anatomy that may be clinically indicated”.

A physician billing company that provides obstetrics medical billing services can help offices report ultrasounds during pregnancy with the appropriate ICD-10 and CPT codes and modifier. Adequate documentation of the study consistent with medical need is essential for high-quality patient care as well as for reimbursement.