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Performing and Documenting the Fetal Anatomy Ultrasound Examination


The midtrimester fetal ultrasound examination (“anatomy scan”) serves as an important checkpoint for evaluation of the pregnancy and its potential risks. It affords an opportunity to compare obstetric dating with fetal biometric measures, and it permits, prior to fetal viability, identification of important structural abnormalities that may significantly alter neonatal prognosis and management. Finally, it allows identification of maternal uterine findings such as uterine fibroids and placental abnormalities (previa, accreta) that may require significant alterations in the obstetric management plan before and after delivery.

The midtrimester fetal anatomy scan is commonly performed to screen for fetal structural anomalies. The Eurofetus study, which assessed the accuracy of midtrimester sonography in identifying fetal anomalies in a large unselected population examined after birth, reported that slightly more than half of the structural defects identified postnatally had been detected on ultrasound.

Subsequently, Gagnon and colleagues evaluated the existing literature regarding the accuracy of second-trimester sonography to identify fetal anomalies and reported that a prenatal ultrasound examination at 18 to 20 weeks’ gestation can detect major structural anomalies in approximately 60% of cases.

Since the first availability of vaginal transducers, investigators have sought to push the window for fetal anatomy diagnosis earlier and earlier. , Recent reviews have suggested great potential for a high rate of anomaly detection with late first-trimester scans, and a practice parameter has been released by the American Institute of Ultrasound in Medicine. There is currently no Current Procedural Terminology (CPT) code to describe this detailed first-trimester examination.

Categorizing Types of Obstetric Ultrasound Examinations

The content of each obstetric ultrasound examination, and its report, depend on the level of detail required to address the specific clinical indication that occasioned the request for evaluation. The various types of examinations are categorized by the CPT Code Set, which is maintained by the American Medical Association through its CPT Editorial Panel. The CPT Code Set describes medical, surgical, and diagnostic services provided in virtually every area of medicine and is designed to facilitate reliable and uniform communication regarding medical and diagnostic services among providers, patients, and accreditation organizations. CPT code books are published annually with updates in every edition, and practitioners should regularly review changes to codes they use. The currently sanctioned and utilized obstetric CPT codes and their descriptions are listed in Table 16.1 .

TABLE 16.1
Current Procedural Terminology Codes for Obstetric Ultrasound Examinations a
CPT Code Description Type of Examination
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation Routine obstetric screening during first trimester. This code is applied for first-trimester ultrasound scans.
76802 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; each additional gestation 76801 plus this code for each additional gestation in multiple pregnancies.
76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (≥14 weeks 0 days), transabdominal approach; single or first gestation Routine obstetric screening after first trimester. This code is used for fetal size and anatomy screening if there are no suspected abnormalities or high-risk conditions.
76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Fetal and maternal evaluation plus detailed fetal anatomic examination. This code is used only once per pregnancy per practice and is applied when the risk of abnormalities is increased, such as due to patient history or by finding during a prior ultrasound examination.
76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, plus detailed fetal anatomic examination, transabdominal approach; each additional gestation 76811 plus this code for each additional gestation in multiple pregnancies.
76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heartbeat, placental location, fetal position, and/or qualitative amniotic fluid volume), one or more fetuses This code is applied for limited scanning to answer a discrete question, such as to establish fetal or cardiac activity or for amniotic fluid assessment.
76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, reevaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus This code is applied for all follow-up or repeat examinations.
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal This code is applied for all transvaginal scanning during pregnancy.
76818 Fetal biophysical profile; with nonstress testing Fetal well-being is assessed via the fetus’s movements, tone, and breathing and amniotic fluid volume. A nonstress test is also performed.
76819 Fetal biophysical profile; without nonstress testing Biophysical profile only: movements, breathing, tone, amniotic fluid.

a Note: Nonvisualization of any of the required fetal or maternal components due to fetal position, gestational age, or maternal body habitus must be clearly noted in the ultrasound report.

CPT codes are submitted for insurance reimbursement, paired with codes from the International Statistical Classification of Diseases and Related Health Problems , 10th Revision (ICD-10), which describe the medical justification for the visit or procedure. Codes for obstetric ultrasound are found in Chapter 15 (Pregnancy, Childbirth, and the Puerperium) of the ICD-10, and all begin with the letter “O.”

The following Chapter 15 codes are usable examples for justifying obstetric ultrasound:

  • O00-O9A Pregnancy, childbirth and the puerperium.

  • O35 Maternal care for known or suspected fetal abnormality and damage.

  • O35.0 Maternal care for (suspected) central nervous system malformation in fetus.

The ICD-10 codes found in Chapter 16 (Certain Conditions Originating in the Perinatal Period) and Chapter 17 (Congenital Malformations, Deformations, and Chromosomal Abnormalities) are used when the mother herself has congenital condition(s). For example, the Q05 Spina Bifida code should be used only when the pregnant woman herself has spina bifida.

All ultrasound examinations require a report in the patient’s medical record, including the indication for the study, relevant findings, and their interpretation. , The content of the report depends on the indication for the ultrasound study, and it should include enough information for clinicians to incorporate the findings into the patient’s care.

In the case of obstetric imaging, the CPT guidelines for each examination type provide very specific elements that must be evaluated and reported in the fetus, placenta, and uterus ( Box 16.1 ).

Box 16.1
Elements for Obstetric Ultrasound Performance and Reporting Required by Major Current Procedural Terminology Code

76801: Pregnancy Less Than 14 Weeks

  • Presence, size, location, and number of gestational sacs and fetuses

  • Gestational sac or crown-rump measurement appropriate for gestational age

  • Documentation of presence of cardiac activity

  • Description of the maternal uterus and adnexa

  • Qualitative assessment of amniotic fluid volume and gestational sac shape

76805: Pregnancy of 14 Weeks or More

  • Number of gestational/chorionic sacs and fetuses with cardiac activity

  • Amniotic fluid volume

  • Four-chamber heart

  • Intracranial, spinal, thoracic, and abdominal anatomy

  • Placenta location

  • Umbilical cord insertion site into placenta

  • Maternal adnexae if visible

76811: Pregnancy, With Detailed Maternal and Fetal Evaluation

  • All elements specified for 76805 (see Box 16.2 )

  • PLUS description of:

    • Third and fourth cerebral ventricles

    • Cerebellar lobes with measurement

    • Cerebellar vermis

    • Cisterna magna with measurement

    • Nuchal thickness measurement (15–20 weeks)

    • Palate

    • Thorax: any masses, effusions; integrity of the diaphragm

    • Ribs

    • Abdominal cavity: presence of ascites

The Basic Midtrimester Fetal Anatomy Scan (CPT 76805)

The “Standard Examination” or basic midtrimester fetal anatomy scan (CPT 76805) should include an evaluation of the following :

  • Fetal cardiac activity

  • Fetal number (and chorionicity if multifetal pregnancy)

  • Fetal structural dimensions and corresponding gestational age estimates

  • Anatomy of major organ structures

  • Placental appearance and location

  • Amniotic fluid (qualitative, or semiquantitative by deepest vertical pocket)

  • Uterine and adnexal anatomy, including lower uterine segment and cervix

The examination should begin with an overview of the uterine contents taken in successive sagittal and transverse sections so that fetal number, viability, lie, placental position, and amniotic fluid can be determined. This information will guide successive transducer placements to facilitate obtaining images to demonstrate specific anatomic features and measurements.

Next, fetal biometry should be obtained for comparison with existing pregnancy dating. The specific fetal structural dimensions to be obtained for gestational age estimation are summarized in Box 16.2 .

Box 16.2
Midtrimester Fetal Biometry and Gestational Age Assessment (CPT 76805)
Modified from International Society of Ultrasound in Obstetrics and Gynecology Clinical Standards Committee. Practice guidelines for ultrasound assessment of fetal biometry and growth. Ultrasound Obstet Gynecol. 2019;53:715–72.

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