OB ultrasound of gestational sac and qualitative assessment of amniotic fluid

Q.

We understand the requirement of documenting why an element can’t be evaluated for a complete ultrasound but are having a disagreement on how detailed that reason must be. The biggest issue is OB ultrasounds (CPT^® code 76801) and the “qualitative assessment of amniotic fluid.” If the patient doesn’t have a gestational sac identified, can “amniotic fluid – no gestational sac identified” be adequate?

A.

Yes, in an early pregnancy, documentation that no gestational sac was seen could account for all required elements except the maternal uterus and adnexa. Consider the following:

Clinical Examples in Radiology, Summer 2010 had a “Documentation Challenge” report: Positive Beta hCG and Pelvic Pain

Part of the discussion was: 

“The patient is clinically pregnant, as indicated by the positive hCG (human chorionic gonadotropin) test; however, there is no mention of a gestational sac, yolk sac, or fetal pole described within the report.

Because the maternal adnexa and uterus are described, an additional statement by the physician that no gestational sac, yolk sac, or fetal pole was visualized would then qualify this procedure as a complete obstetrical ultrasound (code 76801). In the early stages of pregnancy, it may not be possible to visualize these elements. As long as the report notes these elements were sought, there is sufficient documentation to qualify this study as a complete obstetrical ultrasound examination of a less than 14-week pregnancy, and code 76801 should be reported. As this patient is considered clinically pregnant, the coder should discuss the CPT^® coding guidelines with the reporting physician and ask if these elements were sought. If any of the required elements are not documented for a complete obstetrical ultrasound, the limited code (76815) would have to be reported.”

It’s also worth noting that the amniotic fluid assessment requirement in 76801 is a “qualitative” assessment. The documentation doesn’t require an amount, just that it was sufficient, or insufficient.