How To Use CPT Code 76816

CPT 76816 is a follow-up ultrasound code for pregnant uterus, real-time with image documentation, used to re-evaluate fetal size, amniotic fluid volume, and suspected or confirmed abnormalities. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 76816.

1. What is CPT 76816?

CPT 76816 is a medical billing code used for follow-up ultrasound examinations of a pregnant uterus. This code is specifically used when a prior ultrasound has shown abnormalities in the fetus, and a re-evaluation is needed to assess the fetal size, amniotic fluid volume, and any suspected or confirmed abnormalities in the organ system(s).

2. 76816 CPT code description

The official description of CPT code 76816 is: “Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus.”

3. Procedure

1. The provider applies gel on the ultrasound transducer head.
2. The transducer head is placed on the patient’s abdomen.
3. High-frequency sound waves are emitted from the transducer, which travel through the patient’s body and reflect back to the receiver.
4. The monitor receives the sound waves and uses them to create images of the developing fetus.
5. The provider reevaluates the fetal size, amniotic fluid volume, and any suspected or confirmed abnormalities in the organ system(s).

4. Qualifying circumstances

Patients eligible to receive CPT code 76816 services are pregnant women who have had a prior ultrasound showing abnormalities in the fetus. The follow-up ultrasound is necessary to reassess the fetal size, amniotic fluid volume, and any suspected or confirmed abnormalities in the organ system(s).

5. When to use CPT code 76816

It is appropriate to bill the 76816 CPT code when a follow-up ultrasound examination is needed to re-evaluate fetal size, amniotic fluid volume, and any suspected or confirmed abnormalities in the organ system(s) that were identified in a previous ultrasound.

6. Documentation requirements

To support a claim for CPT 76816, the following information should be documented:

• Date of the prior ultrasound that showed abnormalities in the fetus
• Specific abnormalities identified in the prior ultrasound
• Reason for the follow-up ultrasound (e.g., re-evaluation of fetal size, amniotic fluid volume, or organ system abnormalities)
• Findings of the follow-up ultrasound, including any changes or improvements in the previously identified abnormalities
• Images and measurements obtained during the follow-up ultrasound

7. Billing guidelines

When billing for CPT code 76816, it is important to follow these guidelines:

• Use modifier 59 for each additional fetus examined in a multiple pregnancy.
• If reporting only the physician’s interpretation for the radiology service, append professional component modifier 26 to the radiology code.
• If reporting only the technical component for the radiology service, append modifier TC to the radiology code. Note that payer policy may exempt hospitals from appending modifier TC because the hospital’s portion is inherently technical.
• Do not append a professional or technical modifier to the radiology code when reporting a global service in which one provider renders both the professional and technical components.

8. Historical information

CPT 76816 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone the following changes:

• Code Changed on 01-01-2003: Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat
• Code Changed on 01-01-2002: Echography, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat

9. Similar codes to CPT 76816

Five similar codes to CPT 76816 and how they differentiate are:

• CPT 76801: Used for transabdominal ultrasound for fetal and maternal evaluation during the first trimester, not for fetal nuchal translucency.
• CPT 76805: Used for transabdominal ultrasound for fetal and maternal evaluation after the first trimester, not for fetal nuchal translucency.
• CPT 76811: Used for transabdominal ultrasound for fetal and maternal evaluation with additional analysis of the fetal anatomy.
• CPT 76813: Used for either transabdominal or transvaginal ultrasound to measure the fetal nuchal translucency, or the clear, fluid-filled space in the back of the developing fetus’s neck.
• CPT 76815: Used for a limited ultrasound of the pregnant uterus to examine only certain parameters.

10. Examples

Here are 10 detailed examples of CPT code 76816 procedures:

1. Follow-up ultrasound to re-evaluate fetal size after a prior ultrasound showed intrauterine growth restriction.
2. Reassessment of amniotic fluid volume in a patient with a history of oligohydramnios.
3. Follow-up ultrasound to monitor the development of a fetus with a previously identified congenital heart defect.
4. Re-evaluation of a fetus with a suspected brain abnormality detected in a previous ultrasound.
5. Follow-up ultrasound to monitor the progression of a fetus with a previously identified limb abnormality.
6. Reassessment of a fetus with a suspected kidney abnormality detected in a prior ultrasound.
7. Follow-up ultrasound to monitor the development of a fetus with a previously identified cleft lip or palate.
8. Re-evaluation of a fetus with a suspected spinal abnormality detected in a previous ultrasound.
9. Follow-up ultrasound to monitor the progression of a fetus with a previously identified diaphragmatic hernia.
10. Reassessment of a fetus with a suspected gastrointestinal abnormality detected in a prior ultrasound.