Coding for the “new” First Trimester Detailed Diagnostic Obstetric Ultrasound
Vanita Jain MD & Fadi Bsat MD for the SMFM Coding Committee and the Division of Practice Management
In 2020, the AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 weeks 0 days and 13 weeks 6 days was developed in collaboration with ACR, ACOG, PQF, SDMS, SMFM, and SRU. This specialized diagnostic ultrasound examination is an extension of the standard sonographic fetal assessment.
Two recent publications reviewed the standard evaluation of the fetus in the first trimester. In 2016, the ACOG Practice Bulletin titled Ultrasound in Pregnancy, was developed in collaboration between ACOG and AIUM. This document defines a standard first trimester ultrasound as an exam performed before 14 weeks 0 days and provides the following suggested indications for this exam:
- To confirm the presence of an IUP
- To evaluate a suspected ectopic pregnancy
- To evaluate vaginal bleeding
- To evaluate pelvic pain
- To estimate gestational age
- To diagnose or evaluate multiple gestations
- To confirm cardiac activity
- As an adjunct to CVS, embryo transfer, localization and removal of an IUD
- To assess for certain fetal anomalies such as anencephaly in patients at high risk
- To evaluate maternal, pelvic, or adnexal masses or uterine abnormalities
- To screen for fetal aneuploidy
- To evaluate for suspected hydatidiform mole
The document stated the following imaging parameters:
- May be performed TA or TV, or both if TA is inconclusive
- Maternal anatomy must be evaluated: uterus, cervix, adnexa
- Document the location of the GS, the presence or absence of the YS and/or embryo
- If the CRL of an embryo if visualized, it should be utilized for dating
- Mean GS measurement if no embryo is visualized (not to be used for dating)
- Presence/absence of a FHR for viability
- Fetal number, number of amniotic sacs, and chorionicity if multiple gestations
- Embryonic or fetal anatomy should be assessed as appropriate for the gestational age
In 2018, AIUM, ACR, ACOG, SMFM, and SRU collaborated on the Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations. This document provided even more specificity regarding the documentation of specific structures in the first trimester. It defined the indications for a standard first trimester ultrasound exam like the 2016 document:
- To confirm the presence of IUP (as above)
- To evaluate a suspected ectopic (as above)
- To evaluate vaginal bleeding (as above)
- To evaluate pelvic pain (as above)
- To evaluate gestational age (as above)
- To diagnose or evaluate multiple gestations with determination of chorionicity (as above)
- To confirm cardiac activity (as above)
- As an adjunct to CVS, embryo transfer, localization and removal of an IUD (as above)
- To assess for certain fetal anomalies (as above)
- To evaluate maternal pelvic masses or uterine abnormalities (as above)
- Measurement of the NT as part of a screen for aneuploidy (specifically, NT was added)
- To evaluate for gestational trophoblastic disease (same, terminology updated)
The document also reviewed imaging parameters, but in much more detail than the original AIUM-ACOG document:
- May be performed TA or TV, or both if TA is inconclusive
- Maternal anatomy must be evaluated: uterus, cervix, adnexa, adding cul-de-sac (CDS). More detail was given regarding documentation fluid in the CDS. Measurements of any uterine or adnexal anomalies (fibroids, ovarian cysts for example) should be documented.
- Document the location of the GS, the presence or absence of the YS and/or embryo
- CRL of an embryo, if visualized, to be utilized for dating
- Mean GS measurement if no embryo visualized (not to be used for dating)
- Presence/absence of a FHR for viability, adding that this should be documented with a 2D video clip or M-mode
- Fetal number, number of amniotic sacs, and chorionicity if multiple gestations
- Fetal anatomy should be assessed, including calvarium, abdominal cord insertion (ACI), presence of limbs (if fetus of sufficient size)
- The nuchal region should be imaged, and abnormalities such as cystic hygroma documented
- The NT should be measured for those patients desiring to assess their risk of fetal aneuploidy (guidelines for measuring the NT are given)
With improving imaging technology and the development of further diagnostic expertise, centers have increased their recognition of many fetal anomalies by ultrasound in the late first trimester. The development of enhanced diagnostic skill has coincided with the increased need to support women’s access to reproductive options at earlier gestational ages, a position supported by most obstetric societies. This allows patients to partake in the process of shared decision making and express their value-based preferences and provide input on the management of their pregnancy, which facilitates access to their reproductive rights or reproductive choices. Screening for anomalies in the first trimester is supported in the joint ACOG-SMFM document ACOG Practice Bulletin Number 226, Screening for Fetal Chromosome Abnormalities. Testing for chromosomal abnormalities should be an informed patient choice based on the provision of adequate and accurate information and the patient’s clinical context, accessible health care resources, values, interests, and goals. First-trimester screening gives the potential for earlier diagnoses and the ability to screen for other structural, genetic, or placental disorders. Enhanced first trimester anomaly detection is particularly helpful when newer genetic diagnostic options are used, such as DNA probes and whole Exome Sequencing, as these studies take more time to result. It also allows women to seek additional information or obtain the necessary consultations to support pregnancy management and reproductive options.
First‐trimester NT is the primary sonographic marker that is used in combination with serum analytes to determine aneuploidy risk. Sonographer certification and quality assurance are needed to standardize this screening method. Nuchal translucency can be useful in multifetal gestations, in which serum screening methods may not be as accurate, may be unavailable, or cannot provide information specific to each fetus. Other structures can be evaluated in the first trimester as well. The absence of a nasal bone or an absent or reversed ductus venosus Doppler waveform increases the risk for aneuploidy. All patients should be offered a second-trimester ultrasound at 18 to 22 weeks of gestation for fetal structural defects regardless of first trimester imaging since these defects may occur with or without fetal aneuploidy. No one screening test performs flawlessly in all clinical scenarios, and all screening tests detect fewer abnormalities than diagnostic testing that includes microarray analysis. Information regarding gestational age, viability, the number of fetuses, evaluation for a vanishing twin or empty gestational sac, and the presence of an apparent fetal anomaly will affect counseling regarding the risks, benefits, and limitations of testing options. Ultrasound remains as an important tool in providing information to the parents regarding potential fetal outcomes.
To preserve women’s health, reproductive choices, and access to care, the AIUM, in collaboration with obstetric and other imaging societies, developed the latest practice parameter on first trimester fetal anatomy ultrasound. The detailed first trimester obstetric ultrasound exam is an indication-driven examination for women at increased risk for fetal or placental abnormalities that are potentially detectable between 12 weeks 0 days and 13 weeks 6 days gestation. Performance and interpretation of this examination require advanced training, knowledge, and imaging skills. The performance of this detailed first trimester ultrasound should be rare outside of referral practices with special expertise in the identification and diagnosis of fetal anomalies and placental implantation disorders in the first trimester. Eventually, accreditation in the performance of such ultrasound studies may be implemented, as was the case for other obstetric imaging studies. While this first trimester detailed ultrasound may detect many major anomalies, the natural history of some findings is variable, and as such, it is emphasized that this study would not replace the need for a second trimester detailed fetal anatomy survey.
Table 1 – Comparing indications Standard FTU vs. Diagnostic FTU (included in the paper)
Currently, a specific CPT code does not exist for a detailed first trimester fetal anatomy survey. The SMFM Coding Committee and members of the AIUM and the ACOG have discussed various billing options to adequately reflect the work effort involved in performing a detailed first trimester fetal anatomy survey. In singleton gestations, there are currently three codes that may be utilized for obstetric imaging in the first trimester. These are:
· 76801 - Ultrasound, pregnant uterus, real-time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation (76802 is the CPT code for each additional gestation)
· 76813 – Nuchal translucency for a single/first gestation pregnancy; transabdominal OR transvaginal approach (76814 is the CPT code utilized for each additional gestation).
· 76817 – Ultrasound, pregnant uterus, real-time with image documentation, transvaginal approach
To accurately visualize all the required structures of the first trimester detailed anatomy ultrasound, transvaginal imaging may be necessary in about 10-20% of cases. It is the opinion of the SMFM coding committee that the best way to capture the work of this extensive detailed examination is to bill both 76801 AND 76813. In twins, 76802 & 76814 would be added as well. The 76813 and 76814 include TV imaging so the addition of 76817 would NOT be necessary even if TV imaging was required to complete the ultrasound study. This should be an indication-driven study and performed only in line with the indications provided in the parameter.1 In the past, we have instructed our membership NOT to routinely bill 76801 + 76813 in combination without a distinct indication for each CPT code. This advice still stands for most imaging performed in the first trimester. However, if an indication exists as noted in the AIUM parameter,1 billing of 76801 + 76813 would be appropriate. This also applies for multiple gestations. For example, a detailed first trimester anatomy survey in a twin gestation would be billed as 76801 + 76802 + 76813 + 76814.
In summary, our guidance to code 76801 + 76813 (+ 76802 + 76814 if twins) for first trimester detailed diagnostic obstetric ultrasound is to appropriately recognize the work effort in performing a first trimester anatomy survey, if the indication(s) and imaging characteristics are those included in the AIUM parameter. Obtaining a detailed first trimester anatomy survey should not exclude the performance of cfDNA testing when indicated, or a second trimester detailed fetal anatomy survey (76811) when one of its indications exist. In addition, the detailed first trimester ultrasound is indication-driven and may be performed regardless of prior aneuploidy screening.
REFERENCES
1. AIUM Practice Parameter for Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12 weeks 0 days and 13 weeks 6 days. J Ultrasound Med 2020; 9999: 1-16
2. Ultrasound in Pregnancy. ACOG Practice Bulletin Number 175, 2016;128:e241-e256.
3. AIUM-ACR-ACOG-SMF-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations. J Ultrasound Med 2018; 9999: 1-12
4. ACOG Committee Opinion Number 815. Increasing Access to Abortion. Obstet & Gynecol 2020;136:e107-e115.
5. ACOG Committee Opinion Number 819. Informed Consent and Shared Decision Making in Obstetrics and Gynecology. Obstet Gynecol 2021;137:e34-e41.
6. ACOG Practice Bulletin Number 226. Screening for Fetal Chromosome Abnormalities. Obstet Gynecol 2020;136:e48-e69.
7. Whitlow BJ, Economides DL. The optimal gestational age to examine fetal anatomy and measure nuchal translucency in the first trimester. Ultrasound Obstet Gynecol. 1998;11:258-61.
8. Bromley B, Shipp TD, Lyons J, Navathe RS, Groszmann Y, Benacerraf BR. Detection of fetal structural anomalies in a basic first-trimester screening program for aneuploidy. J Ultrasound Med. 2014;33:1737-45.
9. 76811 Task Force. Consensus Report on the Detailed Fetal Anatomic Ultrasound Examination. Indications, Components, and Qualifications. J Ultrasound Med 2014; 33:189-195.
10. Bsat F, Malisch T. Detailed Fetal Anatomic Ultrasound Examination (76811): ICD-10 Indications. J Ultrasound Med. 2016;35:1107-8.
11. SMFM Coding Committee White Paper: Coding for Placenta Accreta Spectrum. Society for Maternal Fetal Medicine website. https://www.smfm.org/coding/white-papers/131-smfm-coding-committee-white-paper-coding-for-placenta-accreta-spectrum. Accessed May 11, 2021.