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A real-time transabdominal obstetrical ultrasound, designated by CPT® Code 76801, is a diagnostic imaging procedure performed during the first trimester of pregnancy, specifically when the gestational age is less than 14 weeks 0 days. This ultrasound is crucial for evaluating both the fetus and the pregnant uterus, as well as the surrounding pelvic structures of the mother. The procedure aims to establish the viability of the embryo or fetus, assess the presence of multiple gestations, and determine fetal age through precise measurements of the gestational sac and fetus. Additionally, it allows for the evaluation of the position of the fetus and placenta, the anatomical structures of the fetus and placenta, and the volume of amniotic fluid. During the procedure, the mother is typically required to present with a full bladder, which enhances the clarity of the ultrasound images. The application of acoustic coupling gel to the skin of the lower abdomen facilitates the transmission of ultrasonic waves. A transducer is then firmly pressed against the skin and moved back and forth over the lower abdomen to capture images of the pregnant uterus, the fetus, and the surrounding pelvic structures. The ultrasound utilizes high-frequency sound waves that are directed at these areas, and the echoes produced are recorded to create visual images. Any abnormalities detected during the examination are thoroughly evaluated. Following the procedure, the physician reviews the obtained ultrasound images and provides a comprehensive written interpretation of the findings. This code, 76801, is specifically utilized for a single gestation or the first gestation in cases of multiple pregnancies during the first trimester, while code 76802 is designated for each additional gestation.
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The ultrasound procedure designated by CPT® Code 76801 is indicated for the following conditions and evaluations during the first trimester of pregnancy:
The procedure for performing a transabdominal obstetrical ultrasound as per CPT® Code 76801 involves several key steps:
After the completion of the ultrasound procedure, the patient may be advised to resume normal activities unless otherwise instructed by the physician. There are typically no specific post-procedure care requirements associated with this ultrasound. However, the patient may be informed about the next steps based on the findings of the ultrasound, including any necessary follow-up appointments or additional testing if abnormalities are detected. The physician will discuss the results with the patient, providing clarity on the health status of the fetus and any implications for the pregnancy moving forward.
| Short Descr | OB US < 14 WKS SINGLE FETUS | Medium Descr | US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT | Long Descr | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 01 - Procedure must be performed under the general supervision of a physician. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Not Discounted when Multiple | ASC Payment Indicator | Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight. | Type of Service (TOS) | 4 - Diagnostic Radiology | Berenson-Eggers TOS (BETOS) | I3B - Echography/ultrasonography - abdomen/pelvis | MUE | 1 | CCS Clinical Classification | 197 - Other diagnostic ultrasound |
This is a primary code that can be used with these additional add-on codes.
| 76802 | Female Edit Addon Code MPFS Status: Active Code APC N ASC N1 PUB 100 CPT Assistant Article Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) |
| 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | CR | Catastrophe/disaster related | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 77 | Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | FY | X-ray taken using computed radiography technology/cassette-based imaging | GA | Waiver of liability statement issued as required by payer policy, individual case | GC | This service has been performed in part by a resident under the direction of a teaching physician | HH | Integrated mental health/substance abuse program | KX | Requirements specified in the medical policy have been met | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | X1 | Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2011-01-01 | Changed | Short description changed. |
| 2007-01-01 | Changed | Code description changed. |
| 2006-01-01 | Changed | Code description changed. |
| 2005-01-01 | Changed | Code description changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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