CPT Code 76857: Pelvic Ultrasound (Nonobstetric), Limited or Follow-up

What is CPT code 76857?

CPT code 76857 refers to a limited or follow-up pelvic ultrasound. It is used when the ultrasound focuses on a specific organ or area, such as the bladder, ovaries, or uterus, rather than performing a full pelvic exam or a follow up to prior findings. The procedure utilizes ultrasound technology to create detailed images that enable healthcare providers to assess reproductive organs and surrounding structures.

The pelvic nonobstetric real-time examination can be performed using either a transabdominal approach or transvaginal ultrasound technique, depending on clinical indications and patient factors. Both methods provide excellent visualization of pelvic anatomy, though the transvaginal examination typically offers superior image quality for evaluating internal reproductive structures. The procedure involves placing an ultrasound transducer either on the abdominal surface or within the vaginal canal to generate sound waves that create detailed images of the female genital tract.

When to do a pelvic ultrasound?

Pelvic ultrasound examinations serve numerous diagnostic purposes in clinical practice. Common indications include evaluation of vaginal bleeding, pelvic swelling, and various symptoms related to gynecological conditions. The ultrasound helps identify malignant neoplasm, benign neoplasm, and masses of uncertain behavior within the reproductive organs.

The procedure proves particularly valuable in infertility treatment protocols, enabling monitoring of follicles during the menstrual cycle and assessment of ovarian response to fertility medications.

Healthcare providers routinely use pelvic ultrasound to evaluate endometriosis, monitor intrauterine device placement, and investigate ectopic pregnancy when clinically suspected.

CPT code 76857 documentation requirements

Comprehensive documentation for CPT 76857 requires detailed recording of clinical indications, technical parameters, and diagnostic findings. This should include:

• Symptoms or clinical presentation that necessitated the ultrasound
• Which pelvic structures were evaluated, and what technical approach was  used
• Time with image documentation specifying the permanent images obtained and stored
• Clear correlation between imaging findings and clinical presentation
• Unspecified complications or uncertain behavior lesions require a detailed description and recommendations for further evaluation or follow-up

CPT code 76857 billing guidelines

Billing for CPT code 76857 requires adherence to established guidelines from the American Medical Association and Medicare Administrative Contractors. Healthcare providers must ensure that the examination scope justifies billing this limited ultrasound code.

The procedure must be performed by qualified personnel using appropriate equipment capable of producing diagnostic-quality images. Payment depends on proper documentation of medical necessity and compliance with coverage requirements established by various payers.

Same-day service limitations

When multiple services are provided on the same day, providers must ensure proper coding and avoid duplicate billing. CPT 76857 represents a limited pelvic ultrasound examination and should not be billed concurrently with other ultrasound procedures that evaluate the same anatomical structures. The provider must document distinct clinical indications if multiple imaging studies are performed during a single encounter.

Other relevant CPT codes

• 76830: Ultrasound, transvaginal
• 76831: Saline infusion sonohysterography (SIS), including color flow Doppler, when performed
• 76817: Transvaginal ultrasound, obstetric, including image documentation; single or first gestation