Coding and billing for transvaginal ultrasound to assess second-trimester cervical length

Transvaginal ultrasound cervical length (TVU CL) assessment is a safe, acceptable, reproducible, and accurate screening test, with potentially widespread availability. However, both proponents and opponents of universal cervical length (CL) screening for increased prematurity risk raise valid issues. Cervical length screening for singleton gestations with or without a prior history of preterm birth is a reasonable strategy. Therefore, implementation of routine second-trimester TVU CL can be a reasonable screening method considered by individual practitioners. Third-party payers should not deny reimbursements for this screening.¹

Technique

Sonographic assessment of CL should be performed only by individuals trained in the technique. A TVU CL assessment needs to be performed with proper technique, quality control, and monitoring to yield accurate results. To ensure quality, the Perinatal Quality Foundation² convened a cervix education task force in November 2011. The goal of the task force was to develop a consensus educational program that presented in a widely available format the standard criteria for sonographic CL measurements during pregnancy. The Cervical Length Education and Review (CLEAR) program is a product of the task force discussions. The CLEAR program provides 3 lectures, an optional examination, and a scored cervical image review. The lectures are available at no charge. Documentation of completion of the CLEAR program, as well as continuing medical education (CME) credits, will be provided to those who complete the lectures and pass the examination and the image review. More information is available at CLEAR: Cervical Length Education and Review (www.perinatalquality.org/CLEAR).³

When performed in low-risk, asymptomatic women for purposes of preterm birth (PTB) screening, a single TVU CL determination obtained between about 18 weeks’ and 24 weeks’ gestation is sufficient. Serial cervical exams are usually not indicated in low-risk women, but they are appropriate in high-risk pregnancies (ie, singleton gestations with prior PTB). Given reports that 57% of short CL on TVU are not detected on transabdominal ultrasound,⁴ and that the TVU screening approach was the one used in all published trials, TVU is the preferred approach for diagnosing cervical shortening. In recognition of the potential value of routine CL screening and the additional technical and time requirements needed to accomplish this assessment, payment for a single TVU examination performed between 18 and 24 weeks’ gestation for CL assessment in low-risk patients (ie, singleton gestations without prior PTB) is appropriate. When screening high-risk patients, a series of TVU CL measurements can be performed every 2 weeks between 16 and 24 weeks.⁵

The SMFM Coding Committee has provided the following guidance for coding cervical screening:

The optimal method for cervical screening is TVU. The Current Procedural Terminology (CPT) Code for this procedure is:⁶

76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal. CPT Code 76817 may be billed alone or with other ultrasound services at the same session. If TVU for cervical screening is performed on the same date of service as a transabdominal ultrasound performed for other clinical indications, both ultrasound procedures would be billed. For example:

76805, Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach;

76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal;

or

76811, Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation;

76817, Ultrasound, pregnant uterus, real time with image documentation, transvaginal.

According to the 2012 American Medical Association CPT:⁶ “If transvaginal examination is done in addition to transabdominal obstetrical ultrasound exam, use 76817 in addition to appropriate transabdominal exam code.” Based on these guidelines, the use of Modifier 59 (Distinct Procedural Service) is not required. However, should payors have specific internal guidelines that require the use of Modifier 59; it would then be attached to the transvaginal ultrasound (CPT 76817).

The International Statistical Classification of Diseases and Related Health Problems: ICD-9 (ICD-9-CM)^6,7 diagnosis code that is recommended for cervical length assessment, in the absence of risk factors or symptoms, is:

V28.82 Encounter for screening for risk of pre-term labor

It is important to clearly document in the body of the ultrasound report that a transvaginal approach was used to assess CL. As always, the SMFM Coding Committee strongly recommends that providers contact their local payors to verify the specific coverage in each contract to avoid delays in claim processing for these coding combinations.

References

1. Society for Maternal-Fetal Medicine, with the assistance of Vincenzo Berghella, MD. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376-386.

2. The Perinatal Quality Foundation. www.perinatalquality.org. Accessed May 13, 2013.

3. CLEAR: Cervical Length Education and Review. www.perinatalquality.org/CLEAR. Accessed May 13, 2013.

4. Hernandez-Andrade E, Romero R, Ahn H, et al. Transabdominal evaluation of uterine cervical length during pregnancy fails to identify a substantial number of women with a short cervix. J Mat Fetal Neo Med. 2012;Mar 16 [Epub ahead of print]. Level II-1.

5. Berghella V, et al. Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth. A meta-analysis. Obstet Gynecol. 2011;117(3):663–671.

6. American Medical Association. CPT-Current Procedural Terminology. www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt.page. Accessed May 13, 2013.

7. Centers for Disease Control and Prevention. International Classification of Diseases, 
Ninth Revision, Clinical Modification (ICD-9-CM). www.cdc.gov/nchs/icd/icd9cm.htm. Accessed May 21, 2013.

Dr. Helfgott is a physician at All Children’s Hospital, Tampa/St. Petersburg, Florida.

This opinion was developed by the Coding Committee of the Society for Maternal-Fetal Medicine with the assistance of Andrew Helfgott, MD. Neither Dr. Helfgott nor any member of the Coding Committee (see the list of 2013 members at www.smfm.org) has a conflict of interest to disclose with regard to the content of this article.

(Disclaimer: The practice of medicine continues to evolve and individual circumstances will vary. Clinical practices may reasonably vary. This opinion reflects information available at the time of acceptance for publication and is not designed nor intended to establish an exclusive standard of perinatal care. This publication is not expected to reflect the opinions of all members of the Society for Maternal-Fetal Medicine.)