No Compromise in MRI

The individual who appears is for illustrative purposes. The person depicted is a model and not a real healthcare professional. US-N/A-2400043 05/24

Have a Question?

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.


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? 


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.