CPT® Code 76802

Add-On Code

1. Indications

The ultrasound procedure designated by CPT® Code 76802 is indicated for various clinical scenarios during the first trimester of pregnancy. The following conditions or reasons may warrant the performance of this ultrasound:

• Evaluation of Fetal Viability - To confirm the presence and health of the embryo or fetus.
• Assessment of Multiple Gestations - To determine if there are multiple embryos or fetuses present in the uterus.
• Fetal Age Determination - To measure the gestational sac and fetus for accurate dating of the pregnancy.
• Fetal and Placental Positioning - To evaluate the position of the fetus and placenta within the uterus.
• Assessment of Amniotic Fluid Volume - To check the amount of amniotic fluid surrounding the fetus, which is crucial for fetal development.
• Evaluation of Maternal Structures - To assess the maternal uterus and adnexa for any abnormalities or concerns.

2. Procedure

The procedure for performing a transabdominal obstetrical ultrasound as per CPT® Code 76802 involves several key steps that ensure accurate imaging and evaluation of the fetus and maternal structures. The following procedural steps are typically followed:

• Preparation of the Patient - The mother is instructed to arrive with a full bladder, which aids in obtaining clearer images during the ultrasound. This is important as a full bladder provides better acoustic windows for visualization.
• Application of Acoustic Coupling Gel - Once the patient is positioned comfortably, a conductive gel is applied to the skin of the lower abdomen. This gel is essential for facilitating the transmission of ultrasonic waves from the transducer to the body and vice versa.
• Transducer Placement and Imaging - The ultrasound transducer is then pressed firmly against the skin of the lower abdomen. The technician or physician sweeps the transducer back and forth over the area to capture real-time images of the pregnant uterus, surrounding pelvic structures, and the fetus. The ultrasonic waves emitted by the transducer penetrate the tissues and reflect back, creating images based on the echoes received.
• Image Documentation - As the images are obtained, they are documented in real-time. This documentation is crucial for later review and interpretation by the physician.
• Evaluation of Abnormalities - Any abnormalities observed during the imaging process are noted for further evaluation. This may include assessing the size and position of the fetus, the condition of the placenta, and the volume of amniotic fluid.
• Review and Interpretation - After the imaging is complete, the physician reviews the ultrasound images, evaluates the findings, and provides a written interpretation that will be used for further clinical decision-making.

3. Post-Procedure

After the completion of the ultrasound procedure, there are several considerations for post-procedure care and follow-up. The mother may be advised to drink fluids to help with bladder recovery, especially if the full bladder was required for the procedure. The physician will discuss the findings from the ultrasound, including any abnormalities detected, and outline the next steps in prenatal care based on the results. If multiple gestations are confirmed, additional monitoring and follow-up ultrasounds may be scheduled to ensure the health of both the mother and the fetuses. It is also important for the mother to report any unusual symptoms or concerns to her healthcare provider following the ultrasound.