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2025 CPT code 76817

Transvaginal ultrasound of the pregnant uterus, real-time with image documentation.

Follow CPT guidelines for diagnostic ultrasound and obstetrical ultrasound. Ensure proper image documentation and a comprehensive written report.Appropriate modifiers should be added if necessary.

Modifiers may be applicable based on the circumstances of the procedure. For example, modifier 26 may be used if the physician only provides professional interpretation services. Modifier 59 may be used to indicate a distinct procedure in certain situations.

Medical necessity is established when the physician orders a transvaginal ultrasound based on clinical indications such as monitoring pregnancy, evaluating vaginal bleeding, or assessing infertility. The clinical reasoning must justify the need for the transvaginal approach compared to a transabdominal approach.

The clinical responsibility involves performing the ultrasound examination, interpreting the images, and documenting the findings in a report for the patient's medical record.This may include a physician or a qualified sonographer.

IMPORTANT:For non-obstetrical transvaginal ultrasound, use code 76830. If a transvaginal exam is performed in addition to a transabdominal obstetrical ultrasound, use 76817 in addition to the appropriate transabdominal exam code.

In simple words: This is an ultrasound scan of the pregnant uterus using a probe inserted into the vagina to get clear images of the baby and mother's organs.Pictures are taken and saved.

This CPT code represents a real-time transvaginal ultrasound examination of the pregnant uterus, which includes image documentation.It is performed to evaluate the fetus and maternal structures. This procedure may be performed separately or in addition to a transabdominal obstetrical ultrasound.

Example 1: A pregnant patient at 16 weeks gestation presents for a routine anatomy scan.The physician orders both a transabdominal and transvaginal ultrasound to visualize fetal anatomy and placental location clearly. Both 76805 and 76817 are used. , A patient presents with vaginal bleeding during the first trimester. A transvaginal ultrasound is used to evaluate for ectopic pregnancy and assess the gestational sac. 76817 is used., A patient is undergoing in-vitro fertilization (IVF) treatment.A transvaginal ultrasound is performed to monitor follicular development.76817 is used.

The documentation should include a detailed description of the procedure, including the patient's position, the transducer used, and the images obtained. The report should describe the findings regarding the fetus, the uterus, and the adnexa.Measurements should be recorded with images, along with any abnormalities observed.

** Always verify payer-specific coding and billing guidelines to ensure accurate reimbursement.This information is for general guidance only and should not be considered medical advice. Consult the official CPT manual and payer guidelines for the most accurate and up-to-date information.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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