Ovarian disorders cause a variety of hormonal and reproductive problems for women. If these issues are identified early, they can be treated and managed. For a pelvic ultrasound, which is primarily used to diagnose such problems in women, radiologists report CPT code 76856. But they can also perform this procedure to diagnose a range of pelvic issues in males.
In this blog, we will discuss the correct application of this code and some billing tips for submitting accurate claims.
CPT Code 76856 – Description
CPT code 76856 refers to a non-obstetric pelvic ultrasound. This ultrasound is generally performed on women who are not pregnant to view and examine various organs and structures, such as the uterus, ovaries, bladder, cervix, and fallopian tubes. It can also be performed on males to view the seminal vesicles, bladder, and prostate gland.
A pelvic ultrasound is a non-invasive imaging technique that uses high-frequency sound waves to generate real-time visuals. The images are shown on a screen and are also saved for future reference.
Scenarios Where CPT Code 76856 is Applicable
The following are some of the applicable scenarios for CPT code 76856.
Polycystic Ovary Syndrome (PCOS)
Let’s imagine a young woman in her early twenties who experiences irregular periods. She consults her gynecologist and tells her that she is also noticing abnormal hair growth on her face, and has suddenly gained a lot of weight within 2 months. The gynecologist suspects PCOS. She orders a pelvic ultrasound to confirm or rule out her suspicion before starting any treatment. The radiologist performs a pelvic ultrasound and bills the service with the CPT code 76856
Ovarian Cysts
Ovarian cysts are one of the common problems in women, especially in their reproductive years. About 10% to 30% of women experience ovarian cysts in their lives.
So let’s discuss a scenario of a 25-year-old woman who experiences extreme pain during her periods and persistent abdominal bloating. She visits her gynecologist to discuss her symptoms. The physician asks her to get a non-obstetric pelvic ultrasound to detect any abnormalities, such as ovarian cysts. A radiologist performs the ultrasound and bills CPT code 76856 for his services.
Uterine Fibroids
Uterine fibroids are most common in women who are in their 30s and 40s. Statistics show that between 20% and 80% of women develop fibroids before they turn 50.
So let’s think of a case of a 42-year-old woman who experiences lower back pain with chronic vaginal discharge. She sees her gynecologist for this problem. Before stating anything with certainty, her gynecologist asks her to undergo a non-obstetric pelvic ultrasound. The radiologist performs the ultrasound as ordered by the physician. So, to bill the ultrasound and collect reimbursement for his services, he can report CPT code 76856.
Prostate Cancer Diagnosis
Now, let’s imagine that a 38-year-old man has been facing issues while urinating (pain, sudden urge to urinate, frequent urination at night, and slow stream). He visits his nearest physician for treatment. The physician makes a note of all the symptoms and orders a pelvic ultrasound to rule out prostate cancer. The radiologist performs the diagnostic pelvic ultrasound and bills his service with CPT code 76856.
Applicable Modifiers for CPT Code 76856
The following are some of the applicable modifiers of CPT code 76856.
Modifier 26
You can apply modifier 26 to CPT code 76856 to highlight the professional component of a non-obstetric pelvic ultrasound. It explains that the physician interpreted the ultrasound images and prepared a report without performing the diagnostic imaging.
Modifier TC
You can apply this modifier when you are only billing for the technical component of the service. Meaning that as the representative of a radiology lab, you are charging for the use of equipment, supplies, and the technician’s services.
CPT Code 76856 – Billing & Reimbursement Guidelines
The following are the billing and reimbursement guidelines for CPT code 76856.
Ensure Correct Application of CPT Code 76856
Healthcare professionals must understand the description of the code before billing it or filing claims. CPT code 76856 clearly indicates a pelvic ultrasound that is non-obstetrical in nature. However, if a fetus is identified during a non-obstetrical ultrasound, you will still bill your services with the same CPT code. You cannot charge it as an obstetric ultrasound even if the physician requests one later.
Provide Detailed Documentation
Documentation plays a significant role in the reimbursement of your services. Hence, you cannot afford to miss out on any crucial information. So here is a general checklist of the information you must include for CPT code 76856.
- Patient’s complete medical record
- An indication of medical necessity for performing a pelvic ultrasound
- ICD-10 codes that justify the patient’s symptoms or diagnosis
- Name and signature of the ordering physician
- Anatomical structures visualized and assessed
- Results/ test findings
Furthermore, according to CPT guidelines, documentation of a complete female pelvic ultrasound examination must include:
- Measurements and description of the uterus and adnexal structures
- Endometrium measurement
- Bladder measurement
- Description of any pelvic pathology
Follow the Payers’ Guidelines
Each payer has its own reimbursement rates and billing requirements. Therefore, you should verify the procedure’s coverage and the reimbursement rates of each insurance payer before submitting claims to them. While some payers permit service bundling, others do not.
Additionally, some payers impose a limit on the frequency of ultrasounds allowed in a year. Or demand prior authorization before the imaging is performed. So, you must carefully review each payer’s reimbursement guidelines.
Final Word
Before we conclude this blog, let’s quickly recap everything we have discussed above. CPT code 76856 is used to report a complete pelvic ultrasound. This imaging study evaluates the pelvic organs and structures for non-obstetric purposes. The examples may include the diagnosis of PCOS, ovarian cysts, uterine fibroids, and prostate cancer in males.
You can append modifiers 26 and TC to specify the components you are billing for. Moreover, you must follow billing best practices, such as attaching detailed documentation and following each payer’s specific billing guidelines, to ensure that your claim is accepted on the first try.
Or, you can choose an alternative – opting for professional radiology billing services, to make your life easier.
