CPT® Code 76810

Add-On Code

1. Indications

The ultrasound procedure designated by CPT® Code 76810 is indicated for the following conditions and evaluations:

• Fetal Viability - To confirm that the fetus is alive and developing appropriately.
• Multiple Gestation - To determine if there are multiple fetuses present in the uterus.
• Fetal Age Assessment - To measure fetal dimensions for estimating gestational age.
• Fetal Position Evaluation - To assess the position of the fetus within the uterus.
• Placental Location - To evaluate the position and health of the placenta.
• Fetal Anatomy Survey - To examine the fetal anatomy, including the brain, spine, abdomen, and heart.
• Umbilical Cord Insertion Site - To identify where the umbilical cord attaches to the placenta.
• Amniotic Fluid Volume Assessment - To evaluate the amount of amniotic fluid surrounding the fetus.
• Maternal Uterus and Adnexa Evaluation - To assess the maternal uterus and any visible adnexal structures.

2. Procedure

The procedure for performing a transabdominal obstetrical ultrasound as per CPT® Code 76810 involves several key steps:

• Preparation of the Patient - The patient 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 facilitates the transmission of ultrasound waves and enhances image quality.
• Transducer Placement - A transducer, which is a handheld device that emits and receives ultrasound waves, is pressed firmly against the skin over the lower abdomen. The sonographer or physician sweeps the transducer back and forth across the area to capture images of the pregnant uterus and surrounding structures.
• Image Acquisition - As the transducer moves, it emits ultrasonic wave pulses directed at the fetus and the surrounding pelvic structures. The echoes produced by these waves are recorded, creating real-time images of the fetus, uterus, and any visible maternal pelvic structures.
• Evaluation of Findings - The sonographer evaluates the obtained images for any abnormalities or areas of concern. This includes assessing fetal anatomy, position, and the condition of the placenta and amniotic fluid.
• Physician Review and Interpretation - After the imaging is complete, the physician reviews the ultrasound images and provides a comprehensive written interpretation of the findings, which is documented for medical records and further clinical decision-making.

3. Post-Procedure

After the completion of the ultrasound procedure, there are typically no specific post-procedure care requirements for the patient. The patient may be advised to resume normal activities unless otherwise instructed by the physician. The results of the ultrasound, including any findings or concerns, will be discussed with the patient during a follow-up appointment or as part of routine prenatal care. It is essential for the patient to understand the implications of the ultrasound findings and any necessary next steps in their prenatal care plan.