Clinical Context
A pregnant patient presents to an outpatient obstetric imaging center for a targeted follow-up transabdominal ultrasound after a prior routine obstetric scan identified an abnormal fetal finding. The initial scan was performed at about 20 weeks' gestation and noted a possible ventricular enlargement and uncertain cerebellar measurements. The obstetrician orders a follow-up fetal reexamination to clarify the abnormality and assess progression. The patient checks in for a focused fetal ultrasound appointment. A sonographer acquires updated biometric measurements, targeted anatomic views, Doppler assessment as indicated, and documents fetal growth, amniotic fluid volume, and the previously identified abnormality. The interpreting maternal-fetal medicine specialist reviews images, compares to the prior study, documents interval change or resolution, and provides diagnostic interpretation and recommendations to the referring provider. Typical documentation includes prior report comparison, targeted exam findings, images stored, and a final interpretation signed by the physician.
Typical site of service: outpatient radiology or obstetric ultrasound suite within a hospital outpatient department or freestanding imaging center.
Typical patient scenario: a second-trimester pregnancy with a prior abnormal transabdominal ultrasound requiring a focused follow-up fetal reexamination for diagnostic clarification and management planning.
Related CPT Codes
| CPT Code | Description | Relationship to This Procedure |
|---|
76805 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, transabdominal; complete | Often performed as the initial comprehensive obstetric ultrasound that may identify abnormalities prompting a follow-up 76816 reexamination |
| 76811 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, transvaginal | May be performed adjunctively when transabdominal visualization is limited and additional pelvic or early gestation detail is needed before or after 76816
| 76817 | Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, transabdominal; follow-up or re-evaluation limited study | An alternative follow-up code for limited re-evaluation of a fetal abnormality; selection depends on documentation and payer guidelines relative to 76816
| 76819 | Ultrasound, pregnant uterus, real time with image documentation, transabdominal and transvaginal; follow-up or re-evaluation | Used when both transabdominal and transvaginal re-evaluation are performed in the follow-up setting alongside or instead of 76816
| 59425 | Antepartum care including ultrasound, first trimester screening and follow-up | Represents global obstetric care codes that may encompass routine ultrasounds; 76816 is billed separately when a specific abnormality follow-up is required
| 99214 | Office or other outpatient visit for evaluation and management, established patient, moderate complexity | May be billed the same day if a medically necessary, separately identifiable E/M service is provided in addition to the ultrasound reexamination