General Question for the Week of June 28, 2021

General Compliance Question of the Week

Question:

I have a question regarding the obstetrical (OB) ultrasound documentation guidelines. I know that the uterus and adnexa are required elements, but some of the providers feel that documenting an IUP should be sufficient for the 1st trimester (76801/76802). For codes 76805/76810, the guidelines state maternal adnexa should be reported “when visible.” So, do the doctors not have to document it when it is not visible?

Answer:

For a complete first trimester OB ultrasound, the maternal uterus and adnexa are required elements. If they can’t be seen, the reason why they can’t be seen must be documented, otherwise, a limited exam must be reported. For 76805/76810, the doctor must still document the maternal adnexa. If they can’t be seen, the doctor must document that, otherwise, a coder or auditor cannot know if they attempted to exam the adnexa and couldn’t, or whether they just didn’t try. In either case, if not documented, a limited exam must be billed.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.