How To Use CPT Code 76802

CPT 76802 describes the use of ultrasound to evaluate the pregnant uterus in real time, documenting images of both the fetus and the mother during the first trimester. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 76802?

CPT 76802 can be used to describe the ultrasound examination of the pregnant uterus during the first trimester. This code is specifically used when the provider performs a transabdominal ultrasound to evaluate each additional gestational sac in addition to the primary fetus.

2. Official Description

The official description of CPT code 76802 is: ‘Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (Use 76802 in conjunction with 76801) (To report first trimester fetal nuchal translucency measurement, use 76814)’

3. Procedure

1. The provider begins by performing an ultrasound examination of the first fetus using a transabdominal approach.
2. After completing the examination of the primary fetus, the provider continues with the same session to perform an additional ultrasound to evaluate each additional gestational sac.
3. The provider applies gel on the ultrasound transducer head and places it on the patient’s abdomen.
4. Using the transducer, the provider slowly moves it over the mother’s abdomen to capture images of the developing fetus(es).
5. The ultrasound waves emitted by the transducer travel through the tissues and are reflected back to create images of the fetus(es) on the monitor.
6. Each additional gestation is examined individually during the same session.

4. Qualifying circumstances

CPT 76802 is used when the provider performs an ultrasound examination of the pregnant uterus during the first trimester and evaluates each additional gestational sac. This code is typically used when there are multiple fetuses present, and the provider needs to assess each one individually.

5. When to use CPT code 76802

CPT code 76802 should be used when the provider performs an ultrasound examination of the pregnant uterus during the first trimester and evaluates each additional gestational sac. It is important to note that this code should only be reported in conjunction with CPT code 76801, which is used for the examination of the primary fetus.

6. Documentation requirements

To support a claim for CPT 76802, the provider must document the following information:

• Indication for the ultrasound examination
• Transabdominal approach used
• Date and time of the examination
• Number of gestational sacs evaluated
• Images obtained during the examination
• Any abnormalities or findings noted
• Signature of the provider performing the examination

7. Billing guidelines

When billing for CPT 76802, it is important to ensure that the examination is performed during the first trimester and that each additional gestational sac is evaluated. This code should be reported in conjunction with CPT code 76801 for the examination of the primary fetus. Modifier 26 should be appended if only the professional component is being reported, and modifier TC should be appended if only the technical component is being reported. However, it is important to review payer policies regarding the use of modifiers.

8. Historical information

CPT 76802 was added to the Current Procedural Terminology system on January 1, 2003. There have been several changes to the code since its addition, including the addition of notes regarding the use of CPT codes 76801 and 76814 in conjunction with 76802.

9. Examples

1. A provider performs an ultrasound examination of the pregnant uterus during the first trimester and evaluates each additional gestational sac in a patient with a multiple pregnancy.
2. During a routine prenatal visit, the provider performs an ultrasound examination of the pregnant uterus and evaluates each additional gestational sac in a patient with twins.
3. A pregnant patient presents with abdominal pain, and the provider performs an ultrasound examination of the pregnant uterus during the first trimester, evaluating each additional gestational sac to assess for any abnormalities.
4. A patient with a history of recurrent miscarriages undergoes an ultrasound examination of the pregnant uterus during the first trimester, and the provider evaluates each additional gestational sac to monitor the progress of the pregnancy.
5. As part of a fertility treatment, the provider performs an ultrasound examination of the pregnant uterus during the first trimester and evaluates each additional gestational sac to confirm the success of the treatment.
6. A patient with a history of ectopic pregnancies undergoes an ultrasound examination of the pregnant uterus during the first trimester, and the provider evaluates each additional gestational sac to rule out any ectopic pregnancies.
7. During a routine prenatal visit, the provider performs an ultrasound examination of the pregnant uterus and evaluates each additional gestational sac in a patient with a multiple pregnancy.
8. A pregnant patient presents with vaginal bleeding, and the provider performs an ultrasound examination of the pregnant uterus during the first trimester, evaluating each additional gestational sac to assess the cause of the bleeding.