Coding for transabdominal studies and transvaginal follow-up evaluation

Q.

Can you please advise what the documentation requirements are when assigning CPT^® code 76830 by itself? The CPT manual does not state any specific elements. If CPT codes 76856 and 76857 are billable for either TA or TV approach, in what situations would it be appropriate to charge for CPT code 76830 by itself and not CPT code 76856/76857?

A.

CPT code 76856 describes only a transabdominal imaging study. CPT code 76857, however, is supposed to be transabdominal but may also be used for transvaginal follow-up evaluation for follicles.

The AMA and ACR state: “It is important to note that all the (pelvic) ultrasound codes are considered transabdominal, unless the approach is otherwise explicitly specified in the code descriptor (eg, transvaginal or intraoperative).” (Clinical Examples in Radiology, Spring 2020). This should mean that 76857 is strictly transabdominal because it does not state the approach. However, the ACR Ultrasound Coding User’s Guide says that CPT code 76857 is appropriate to report for repeated transvaginal follicle evaluation.

While CPT code 76830 does not have a description of documentation requirements in the CPT book, when asked in CPT Assistant, the AMA refers to the ACR Ultrasound Coding User’s Guide which says:

“76830 Ultrasound, transvaginal

This code describes an exam that may include evaluation of the uterus, endometrium, ovaries, and adnexa. When combined with transabdominal ultrasound of the pelvis, add 76856 or 76857. CPT code 76830 is also known as an endovaginal ultrasound for visualization of the endometrium, uterus, and other internal structures. If a translabial or transvaginal ultrasound is performed for external signs and symptoms use CPT code 76857, limited pelvis.

CPT code 76856 or 76857 may be reported together with code 76830 when clinically appropriate, however, it is not intended to be reported together with code 76830 for every patient.”