How To Use CPT Code 76801

CPT 76801 is a code used for ultrasound of a pregnant uterus during the first trimester, with a focus on fetal and maternal evaluation. This article will cover the description, procedure, qualifying circumstances, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 76801.

1. What is CPT 76801?

CPT 76801 is a medical billing code used for the procedure of ultrasound imaging of a pregnant uterus during the first trimester (less than 14 weeks of pregnancy). This code is specifically used for fetal and maternal evaluation, with real-time image documentation, using a transabdominal approach.

2. 76801 CPT code description

The official description of CPT code 76801 is: “Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (less than 14 weeks 0 days), transabdominal approach; single or first gestation.”

3. Procedure

The 76801 procedure involves the following steps:

1. The patient is positioned comfortably on an examination table, with the abdomen exposed.
2. A gel is applied to the patient’s abdomen to improve the transmission of ultrasound waves.
3. An ultrasound transducer is placed on the patient’s abdomen and moved around to obtain images of the developing fetus and female pelvic structures.
4. Real-time images are captured and documented for fetal and maternal evaluation.
5. The ultrasound examination is completed, and the gel is removed from the patient’s abdomen.
6. The provider reviews the images and documents the findings in the patient’s medical record.

4. Qualifying circumstances

Patients eligible to receive CPT code 76801 services are pregnant women in their first trimester (less than 14 weeks of pregnancy) who require an ultrasound examination for fetal and maternal evaluation. This may include women with a history of pregnancy complications, those experiencing symptoms that warrant further investigation, or those undergoing routine prenatal care.

5. When to use CPT code 76801

It is appropriate to bill the 76801 CPT code when a provider performs a transabdominal ultrasound examination of a pregnant uterus during the first trimester, focusing on fetal and maternal evaluation with real-time image documentation. This code should be used for single or first gestation only.

6. Documentation requirements

To support a claim for CPT 76801, the following information should be documented in the patient’s medical record:

• Indication for the ultrasound examination (e.g., routine prenatal care, history of pregnancy complications, or specific symptoms)
• Date and time of the ultrasound examination
• Details of the ultrasound examination, including the transabdominal approach and real-time image documentation
• Fetal and maternal evaluation findings, including any abnormalities or concerns identified
• Provider’s interpretation of the ultrasound images and any recommendations for further evaluation or management

7. Billing guidelines

When billing for CPT code 76801, it is important to follow these guidelines:

• Use add-on code +76802 for each additional gestation sac examined during the ultrasound.
• Use alternative codes for ultrasounds performed after the first trimester or for different purposes, as outlined in the “Similar codes to CPT 76801” section below.
• Append modifier 26 for the physician’s interpretation of the radiology service, or modifier TC for the technical component of the service, as appropriate.
• Do not append a professional or technical modifier when reporting a global service in which one provider renders both components.

8. Historical information

CPT 76801 was added to the Current Procedural Terminology system on January 1, 2003. There have been several updates to the code description since then, with the most recent change occurring on January 1, 2007.

9. Similar codes to CPT 76801

Five similar codes to CPT 76801 and how they differentiate are:

• CPT 76802: Used for transabdominal ultrasound of each additional gestation sac examined during the same session.
• CPT 76805: Used for transabdominal ultrasound performed after the first trimester.
• CPT 76811: Used for transabdominal ultrasound with additional analysis of fetal anatomy.
• CPT 76813: Used for measuring fetal nuchal translucency during the first trimester, either transabdominal or transvaginal.
• CPT 76815: Used for limited ultrasound of the pregnant uterus, examining only specific parameters.

10. Examples

Here are 10 detailed examples of CPT code 76801 procedures:

1. A pregnant woman at 10 weeks gestation undergoes a routine first trimester ultrasound for fetal and maternal evaluation.
2. A pregnant woman with a history of miscarriages has an ultrasound at 8 weeks gestation to assess fetal development and maternal health.
3. An ultrasound is performed on a pregnant woman at 12 weeks gestation due to concerns about potential abnormalities in the developing fetus.
4. A pregnant woman experiencing abdominal pain undergoes an ultrasound at 6 weeks gestation to evaluate the fetus and maternal structures.
5. A first trimester ultrasound is performed on a pregnant woman with a family history of genetic disorders to assess fetal development and maternal health.
6. An ultrasound is conducted on a pregnant woman at 9 weeks gestation to confirm the presence of a single fetus and evaluate maternal structures.
7. A pregnant woman with a history of ectopic pregnancies undergoes an ultrasound at 7 weeks gestation to assess the location of the developing fetus and evaluate maternal health.
8. An ultrasound is performed on a pregnant woman at 11 weeks gestation to assess fetal growth and development, as well as maternal structures.
9. A pregnant woman with gestational diabetes undergoes an ultrasound at 13 weeks gestation to evaluate the developing fetus and maternal health.
10. An ultrasound is conducted on a pregnant woman at 5 weeks gestation due to concerns about potential complications, with a focus on fetal and maternal evaluation.