Summary & Overview
CPT 76831: Hysterosonography with Saline Infusion Ultrasound
CPT code 76831 denotes a diagnostic ultrasound procedure—hysterosonography—where saline is infused into the uterine cavity to enhance endometrial and intrauterine lesion visualization; color flow Doppler may be used. This imaging technique is clinically important for evaluating abnormal uterine bleeding, uterine structure, and intrauterine pathology when transvaginal ultrasound is inconclusive. Nationally, appropriate coding of 76831 affects imaging utilization tracking, prior authorization processes, and payment for gynecologic diagnostic services.
Key payers considered include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the code's clinical context and service setting, followed by benchmark considerations and common payer coverage patterns. The publication outlines typical sites of service (outpatient radiology or gynecology clinics, ambulatory surgical centers, and hospital outpatient departments), expected clinical indications, and coding nuances relevant to billing teams and administrative staff. Where available, the report highlights benchmark measures and recent policy updates that influence authorization and reimbursement practices for hysterosonography. Data not available in the input is explicitly noted in relevant sections.
Billing Code Overview
CPT code 76831 describes an ultrasound procedure in which the provider performs hysterosonography by infusing saline into the uterine cavity to improve visualization. The description notes that color flow Doppler may be used to enhance imaging.
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Service type: Diagnostic ultrasound with intrauterine saline infusion (hysterosonography)
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Typical site of service: Outpatient radiology or gynecology clinic, ambulatory surgical center, or hospital outpatient department
Clinical & Coding Specifications
Clinical Context
A 34-year-old woman with a history of abnormal uterine bleeding is referred to the gynecology clinic for evaluation of suspected intrauterine pathology after an initial pelvic ultrasound suggested a possible endometrial polyp. The patient is not pregnant and has no active pelvic infection. In the outpatient ambulatory ultrasound suite, the gynecologist or radiologist explains the procedure, obtains informed consent, and positions the patient in lithotomy. A sterile speculum is inserted and the cervix cleansed. A small transcervical catheter is advanced into the uterine cavity and sterile saline is slowly infused while a transvaginal ultrasound transducer images the endometrial cavity in real time. Color flow Doppler may be used to better delineate vascular lesions. Images and cine loops are acquired and documented. The provider interprets findings and documents indications, technique (saline infusion sonohysterography), amount of saline, use of color Doppler, patient tolerance, and any complications. The typical site of service is an outpatient radiology or gynecology clinic/ambulatory procedure room; pre-procedure screening and post-procedure recovery occur in the same facility. The service performed corresponds to 76831.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
26 | Professional component | Use when billing only the interpreting physician's professional work and technical component billed separately. |