For a complete first trimester OB ultrasound, the maternal uterus and adnexa are required elements. If they can’t be seen, the reason must be documented or a limited exam must be reported.

Q.

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 1^st 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? 

A.

For CPT^® codes 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 image the adnexa and couldn’t, or whether they just didn’t try. In either case, if not documented, a limited exam CPT code must be billed.