2025 CPT code 76813
Effective Date: N/A Radiology - Diagnostic Ultrasound Feed
Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation
Modifiers may be applicable in certain situations. For example, modifier 52 may be used for reduced services if the procedure is not completed as intended. Modifier 26 is used to indicate the professional component of the service (interpretation only).
Medical necessity for the NT ultrasound is established by the patient’s pregnancy and the request for first-trimester screening for chromosomal abnormalities. It is considered a standard component of prenatal care for assessing fetal risk and providing informed decision-making regarding further diagnostic testing.
The physician's role includes explaining the procedure to the patient, obtaining informed consent, performing or supervising the ultrasound examination (either transabdominal or transvaginal), interpreting the ultrasound images and NT measurement, and counseling the patient on the results and any necessary follow-up actions.If the NT measurement is abnormal, it is crucial to appropriately counsel the patient and discuss the need for further testing such as chorionic villus sampling (CVS) or amniocentesis for a definitive diagnosis.
In simple words: This is an ultrasound test done during the first trimester of pregnancy. It measures the fluid buildup at the back of the baby's neck. This helps determine the chance of the baby having conditions like Down syndrome or heart problems.
This code describes a first-trimester ultrasound procedure used to measure the fetal nuchal translucency (NT).The NT is the sonographic appearance of a collection of fluid under the skin behind the fetal neck. This measurement, taken between 11 and 14 weeks of gestation, helps assess the risk of chromosomal abnormalities and certain other conditions. The procedure involves using either a transabdominal or transvaginal approach with real-time ultrasound and image documentation. The code applies to the measurement of the NT in a single or first gestation.
Example 1: A 32-year-old woman presents for her first prenatal visit at 12 weeks gestation.She opts for first-trimester screening, which includes the NT ultrasound (76813) along with serum blood tests. The ultrasound reveals an NT measurement of 2.5mm, which is considered within the normal range., A 28-year-old woman with a family history of Down syndrome undergoes NT ultrasound at 13 weeks gestation. The NT measurement is 4.0mm, which is above the normal range. The physician counsels the patient about the increased risk of chromosomal abnormalities and recommends diagnostic testing., A pregnant woman at 11 weeks undergoes an NT ultrasound, and along with other markers like nasal bone assessment and blood tests, is found to have a high-risk pregnancy.The physician discusses additional diagnostic and management options.
Documentation should include the indication for the NT ultrasound, the gestational age by ultrasound with crown-rump length (CRL), details of the ultrasound technique (transabdominal or transvaginal), the NT measurement in millimeters, images of the NT measurement, interpretation of the findings, any other abnormalities detected, and recommendations for further testing or counseling if required.
- Specialties:Obstetrics and Gynecology, Maternal-Fetal Medicine, Radiology
- Place of Service:Office, Outpatient Hospital, Freestanding Imaging Center