Transvaginal and Transabdominal Ultrasonography
The ACOG Coding Department has received several questions recently relating to reporting transvaginal and transabdominal ultrasounds during the same session.
Physicians or Other Qualified Healthcare Providers may perform both transvaginal and transabdominal ultrasound examinations on the same patient during the same encounter. Although Medicare’s Correct Coding Initiative does not bundle transabdominal and transvaginal ultrasound codes, these services should only be reported to the insurer if there is documented medical necessity or if the initial examination was inconclusive.
If there was medical necessity and both services are supported by documentation, both studies can be reported. If each ultrasound was performed for a distinct medical reason, report both ultrasound codes linked to different diagnosis codes to support the medical necessity for providing the service.
When multiple ultrasound procedures are performed, the highest valued ultrasound procedure is listed first on the claim form. Modifier 51 (Multiple procedures) is not required.
Both medical necessity and adequate documentation is required to accurately choose an appropriate code when reporting services rendered. Following are the CPT documentation requirements for reporting ultrasound codes:
- A separate, final written report with interpretation of the findings of the imaging procedure.
- Permanently recorded images with measurements when measurements are clinically indicated.
Keep in mind that ultrasounds performed without a thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, are not separately reportable.