2025 CPT code 76816

Follow-up ultrasound of the pregnant uterus, transabdominal approach, per fetus, to re-evaluate fetal size, amniotic fluid volume, or specific fetal anatomy.

Code 76816 is reported per fetus. If more than one fetus is examined, modifier 59 should be appended for each additional fetus after the first. This code should only be used for follow-up examinations, a prior ultrasound must have been performed. This code is for a transabdominal approach. Distinct from 76817, which is a transvaginal approach.

Modifiers applicable: 26 (Professional Component), TC (Technical Component), 59 (Distinct Procedural Service), 76 (Repeat Procedure by Same Physician), 77 (Repeat Procedure by Another Physician), 78 (Return to Operating Room). Modifier 59 is required for each additional fetus after the first.

Medical necessity for this code is established by the need to re-evaluate a previously identified concern or abnormality, monitor fetal growth, or reassess amniotic fluid levels. The previous ultrasound findings and the clinical indication for the follow-up should be clearly documented.

In simple words: This is a follow-up ultrasound during pregnancy done through the abdomen. It is used to check the baby's growth, the amount of fluid around the baby, or to look again at a specific part of the baby that may not have looked normal on a previous ultrasound. If you are pregnant with multiples, the doctor bills this code for each baby checked.

Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus. (Report 76816 with modifier 59 for each additional fetus examined in a multiple pregnancy)

Example 1: A pregnant woman had an ultrasound that showed a possible heart defect in the fetus. She returns for a follow-up ultrasound to re-evaluate the fetal heart., A pregnant woman with twins had a previous ultrasound. She returns for a follow-up ultrasound to assess the growth of each fetus and check the amniotic fluid levels., A pregnant woman had a previous ultrasound showing low amniotic fluid levels.She is sent for a follow-up ultrasound specifically to reassess the amniotic fluid volume.

Documentation must include the indication for the follow-up ultrasound (e.g., previous abnormal findings, concerns about fetal growth).Images, measurements of standard growth parameters and amniotic fluid volume, and a detailed description of the findings must be documented.If a specific organ system is being re-evaluated, detailed examination and findings of that system should be documented. The number of fetuses examined must also be documented.

** Code 76816 should not be reported in conjunction with a complete ultrasound examination (76805 or 76811) during the same encounter.

  • Specialties:Obstetrics, Maternal-Fetal Medicine, Radiology
  • Place of Service:Office, Outpatient Hospital, Inpatient Hospital
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