CPT Code 76830: Non-obstetrical transvaginal pelvic ultrasound

What is CPT code 76830?

CPT code 76830 refers to a non-obstetrical transvaginal ultrasound used to evaluate female pelvic organs, including the uterus, endometrium, ovaries, and adnexa. This diagnostic ultrasound procedure is performed using a probe inserted into the vagina to provide high-resolution images of the female genital tract. It is typically used for assessing pelvic pain, irregular menstruation, pelvic swelling, suspected endometrial cancer, infertility treatment monitoring, or unexplained vaginal bleeding.

This code is distinct from obstetric evaluations, as it is specifically used for non-pregnant patients. CPT 76830 may be reported once per session, regardless of laterality, and includes the real-time image acquisition, interpretation, and report generation by the same physician or healthcare provider.

Documentation requirements

To ensure compliance and support medical necessity, thorough documentation is essential when billing CPT 76830. The following elements should be included in the patient’s medical record:

Clinical indication and medical necessity

The provider must document the reason for the transvaginal ultrasound procedure, such as abnormal uterine bleeding, pelvic mass, evaluation of an ovarian cyst, or monitoring response during infertility treatment. The note should clarify why a transvaginal rather than transabdominal approach was used.

Anatomical focus and image acquisition

The record must specify which female genital organs were evaluated, typically including the uterus, ovaries, and endometrium. Images must be stored permanently, and the interpretation should detail size, shape, and any abnormalities observed.

Interpretation and report

CPT 76830 includes the professional component, so a written interpretation and report must be completed. This should include clinical findings, impressions, and any recommendations for further evaluation or follow-up.

Avoidance of duplicate billing

If a transabdominal pelvic ultrasound (CPT 76856 or 76857) is performed in the same session, it must be documented as medically necessary and distinct from the transvaginal scan. Otherwise, it may be flagged as a duplicate billing error by payers.

Billing guidelines

Correct billing of CPT 76830 is essential for reimbursement and avoiding audit triggers, especially when combined with other pelvic ultrasound codes.

One unit per session

CPT 76830 should be billed once per encounter, even if multiple pelvic structures are assessed or repeat views are captured during the same scan. It represents a complete transvaginal evaluation of the female pelvis.

Modifier use and same-session imaging

If both transabdominal and transvaginal ultrasounds are performed during the same session, use modifier -59 (or XS for Medicare) to indicate distinct services. Documentation must clearly justify why both approaches were necessary, such as in cases of unspecified complications or incomplete visualisation during one modality.

Non-obstetric use only

This code is used only for non-obstetrical indications. For imaging related to pregnancy or obstetric assessment, different codes, such as 76817 for transvaginal obstetric ultrasound, should be used.

Other relevant CPT codes

• 76856 – Complete pelvic ultrasound, non-obstetric, transabdominal
• 76857 – Limited or follow-up pelvic ultrasound, transabdominal
• 76831 – Saline infusion sonohysterography
• 76817 – Transvaginal obstetric ultrasound