Coding Decoded

Coding GYN Ultrasound 
Part 1: 

The most commonly billed codes for a pelvic ultrasound encounter are 76856 (complete transabdominal pelvic) and 76830 (transvaginal pelvic). These exams evaluate pelvic organs including the uterus (and endometrium), adnexa, and other pelvic structures as clinically indicated. While CPT description does not provide a rigid checklist of required measurements, society practice parameters and many payer policies expect documentation of key measurements (typically uterine size, endometrial thickness, and ovarian dimensions) and a description of pertinent pathology. 

Usually, the image acquisition is performed by a sonographer, and the interpretation is performed by a physician. For Medicare and many payers, these diagnostic tests commonly fall under general supervision (meaning the physician does not have to be physically present during image acquisition), though requirements vary by payer and site of service. Documentation must include a written report, and images must be retained as part of the permanent record (electronic storage is preferred; paper retention may be acceptable depending on local policy and payer rules). 

Codes 76856 and 76830 may both be reported when both a complete transabdominal pelvic ultrasound and a transvaginal pelvic ultrasound are actually performed and documented, but payer policies vary, and denials/bundling can occur. When you perform both, document a clear clinical rationale for adding the second approach beyond ‘better visualization’—for example, targeted assessment of the endometrium in postmenopausal bleeding, characterization of an adnexal mass, or limited visualization on the initial approach. Many practices incorporate generic phrases in their report such as, “to obtain a better visualization of the pelvic organs,” that may not be enough and would be subject to scrutiny.  

Compared with 76830/76856, there is a limited/follow-up pelvic ultrasound code (76857), usually used for focused follow-up (e.g., confirming resolution of a likely physiologic cyst) or a specific question (e.g., checking IUD position after placement). Many payers have policies that may restrict billing a complete study again within a short interval. 

If ultrasound is used intra-procedurally (for example, to guide a difficult procedure), the documentation must clearly state that ultrasound guidance was medically necessary and describe why. Whether a modifier (e.g., -59) is appropriate depends on the specific ultrasound guidance code used and the payer’s bundling edits—this should not be used routinely and should be reserved for clearly distinct, medically necessary circumstances. 

We’ll talk about special cases related to ultrasound coding in a future Coding Decoded – happy coding and stay warm!