How To Use CPT Code 76857

CPT 76857 refers to a limited or follow-up nonobstetric pelvic ultrasound procedure. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 76857.

1. What is CPT 76857?

CPT 76857 is a code used to describe a limited or follow-up nonobstetric pelvic ultrasound procedure. This noninvasive diagnostic imaging technique is employed to assess specific pelvic structures and is typically performed to follow up on previous findings or to evaluate a limited number of structures in the pelvis.

2. 76857 CPT code description

The official description of CPT code 76857 is: “Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, for follicles)”.

3. Procedure

1. The patient is positioned comfortably on the examination table.
2. Conductive gel is applied to the skin over the pelvic region to facilitate the transmission of sound waves.
3. A transducer, a device that sends and receives high-frequency sound waves, is pressed against the skin and moved over the area being studied.
4. Real-time images of the pelvic structures are displayed on a monitor and recorded for documentation purposes.
5. The procedure is completed, and the patient is free to leave.

4. Qualifying circumstances

Patients eligible to receive CPT code 76857 services include those who require a follow-up or limited evaluation of one or more pelvic structures, such as the bladder, ovaries, uterus, cervix, and fallopian tubes in females, and the bladder, prostate gland, and seminal vesicles in males. This procedure is typically performed to reevaluate findings from a previous ultrasound or to assess a limited number of structures in the pelvis.

5. When to use CPT code 76857

It is appropriate to bill the 76857 CPT code when a limited or follow-up nonobstetric pelvic ultrasound is performed to evaluate specific pelvic structures, either to follow up on previous findings or to assess a limited number of structures in the pelvis. This code should not be used for complete pelvic ultrasound examinations or when other, more specific codes apply.

6. Documentation requirements

To support a claim for CPT 76857, the following information should be documented:

• Patient’s medical history and reason for the ultrasound
• Specific pelvic structures examined
• Findings and observations during the ultrasound
• Comparison with previous imaging studies, if applicable
• Interpretation and conclusions drawn from the ultrasound
• Images and/or video clips obtained during the procedure

7. Billing guidelines

When billing for CPT code 76857, it is essential to follow the appropriate guidelines and rules. Some tips and related codes to consider include:

• Use CPT code 76856 for a complete transabdominal pelvic ultrasound.
• Use CPT code 76830 for a transvaginal pelvic ultrasound.
• Consider using CPT code 76857 for a limited bladder ultrasound instead of CPT code 76775.
• Use CPT code 76872 for a transrectal ultrasound to examine the prostate, rectum, and surrounding structures in males.

8. Historical information

CPT 76857 was added to the Current Procedural Terminology system on January 1, 1990. There have been updates to the code description since its addition:

• Code Changed on 01-01-2002: Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up (eg, for follicles)
• Code Changed on 01-01-2007: Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up (eg, for follicles)

9. Similar codes to CPT 76857

Five similar codes to CPT 76857 and how they differentiate are:

• CPT 76856: Complete transabdominal pelvic ultrasound
• CPT 76830: Transvaginal pelvic ultrasound
• CPT 76775: Retroperitoneal ultrasound (eg, renal, aorta, nodes), real-time with image documentation; limited
• CPT 76872: Transrectal ultrasound of the prostate, rectum, and surrounding structures in males
• CPT 76700: Complete abdominal ultrasound

10. Examples

Here are 10 detailed examples of CPT code 76857 procedures:

1. Follow-up ultrasound to monitor ovarian cysts in a female patient
2. Limited evaluation of the bladder for suspected urinary retention
3. Assessment of the prostate gland in a male patient with elevated PSA levels
4. Follow-up ultrasound to monitor the size of uterine fibroids
5. Evaluation of the seminal vesicles in a male patient with infertility concerns
6. Assessment of the cervix in a female patient with abnormal Pap smear results
7. Follow-up ultrasound to monitor the resolution of a pelvic inflammatory disease
8. Limited evaluation of the fallopian tubes in a female patient with a history of ectopic pregnancy
9. Assessment of the uterus in a female patient with abnormal uterine bleeding
10. Follow-up ultrasound to monitor the size and position of an intrauterine device