Limited or follow-up transvaginal or pelvic ultrasound exam

Q.

We are in a discussion with our OB/GYN providers on when it is appropriate to assign CPT^® code 76857. Is there a specific approach designated for coding? Can CPT code 76857 be used for either a transvaginal or transabdominal approach? 

A.

According to the American College of Radiology (ACR) Ultrasound Coding User’s Guide, CPT code 76857 may be used for a limited transvaginal exam (e.g., for follicle evaluation).

The code and full description are as follows:

76857   Ultrasound, pelvic (non-obstetric), real time with image documentation; limited or follow-up (e.g., for follicles)