2025 CPT code 76857

Limited pelvic ultrasound, real-time with image documentation; limited or follow-up.

Adhere to CPT guidelines for ultrasound coding. Ensure the examination is appropriately documented as limited and justify the focus on specific structures.A complete exam (76856) should not be billed in the same session if a limited exam (76857) is also performed for the same anatomical region.

Modifiers may apply based on the circumstances of the service. For example, modifier -59 might be used to indicate that the limited ultrasound is distinctly separate from other services performed on the same day. Consult the CPT guidelines for proper modifier use.

Medical necessity is established by the referring physician's clinical findings and indications for performing a limited pelvic ultrasound.This could include suspected pathology, follow-up on previous findings, or a need to assess specific pelvic organs.

The physician or qualified technician performs the ultrasound, interprets the images, and generates a written report. This includes positioning the patient, applying gel, manipulating the transducer, obtaining images, and interpreting the results.

IMPORTANT May be used in conjunction with 76830 (transvaginal ultrasound) if both approaches are used.76856 (complete pelvic ultrasound) is used when a complete evaluation of pelvic structures is performed.If only bladder imaging is performed without kidney evaluation, 76857 is preferred over 76770.If bladder volume or post-void residual measurement is obtained without bladder imaging, 51798 should be used.

In simple words: This code describes a focused pelvic ultrasound, meaning only certain parts of the pelvis are examined.The doctor uses sound waves to create images of specific areas, and these images are saved. This is often used to check on previous findings or look at a particular problem.

This CPT code represents a non-obstetric pelvic ultrasound examination using real-time imaging with image documentation.It is a focused or limited examination, encompassing a subset of the elements included in a complete pelvic ultrasound (CPT code 76856). This code is appropriate for follow-up examinations or when assessing a limited number of pelvic structures.The procedure may focus on specific areas or organs identified during a prior examination or to assess a limited area of concern. The examination must include image documentation and a written report.

Example 1: A patient presents with pelvic pain. A limited ultrasound focusing on the ovaries and uterus is performed to investigate the cause of pain. Code 76857 is used., Following a previous complete pelvic ultrasound (76856) showing a small ovarian cyst, a follow-up limited ultrasound (76857) is conducted to monitor the cyst's size and characteristics. , A patient complains of bladder discomfort. A focused ultrasound examination of the bladder is performed using a transabdominal approach. Since the kidneys are not included, 76857 is used.

Permanent image documentation, detailed measurements (when applicable), written report describing the findings, and indication for the limited exam.If structures are not visualized, reasons should be documented (e.g., bowel gas).

** Always refer to the most current CPT codebook and coding guidelines for the most up-to-date information.Local payer specific rules may also affect reimbursement.

  • Payment Status: Active
  • Modifier TC rule: The technical component (TC) modifier is not typically applicable to this code.
  • Specialties:Obstetrics and Gynecology, Urology, Radiology
  • Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center
** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.