76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal, single or first gestation

CPT code 76811 represents a specialized diagnostic ultrasound procedure referred to as a detailed fetal anatomic examination. This procedure is distinct from the routine fetal survey (76805) and is specifically indicated when there is a known or suspected risk of fetal anomaly. The examination is typically performed between 18 and 22 weeks of gestation and involves a comprehensive assessment of fetal anatomy, including the fetal brain (specifically evaluating the ventricles, cerebellum, and cisterna magna), the face (examining for cleft lip or palate and orbital spacing), and the heart (going beyond the four-chamber view to include the outflow tracts). Furthermore, the scan includes a thorough evaluation of the fetal spine in multiple planes, the abdominal wall, the gastrointestinal system (stomach location and size), the genitourinary system (kidneys and bladder), and all four extremities including the presence and morphology of long bones, hands, and feet. Maternal components such as the placenta (location and relationship to the internal os), the amniotic fluid volume (AFV), and the umbilical cord (number of vessels) are also meticulously documented. This level of detail is required to provide a definitive assessment when screening results are abnormal or when maternal conditions such as pre-gestational diabetes or exposure to teratogenic medications increase the risk of structural defects. Documentation must reflect the visualization of all required elements to support the use of this code, as it carries a higher work relative value unit (RVU) compared to standard obstetric ultrasounds. It is often performed by a maternal-fetal medicine specialist or a sonographer with advanced training in identifying subtle structural abnormalities. The final report must be comprehensive and detail all assessed systems to satisfy the requirements for this advanced procedural code.

Clinical Indications

  • Suspected fetal structural anomaly
  • Abnormal maternal serum screening (e.g., cell-free DNA or quad screen)
  • History of a previous child with a congenital malformation
  • Advanced maternal age (typically 35 or older at delivery)
  • Pre-gestational diabetes mellitus
  • Exposure to known teratogens or medications associated with birth defects
  • In vitro fertilization (IVF) pregnancy
  • High-risk multiple gestation
  • Presence of maternal alloimmunization

Procedure Steps

  1. Verification of fetal number and viability
  2. Measurement of fetal biometry including biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL)
  3. Detailed intracranial survey including the lateral ventricles, choroid plexus, cavum septum pellucidum, cerebellum, and cisterna magna
  4. Assessment of the facial profile, including the presence of the nasal bone and integrity of the upper lip/palate
  5. Comprehensive cardiac evaluation including the four-chamber view, left ventricular outflow tract (LVOT), and right ventricular outflow tract (RVOT)
  6. Survey of the thorax and assessment of the diaphragm and lung echogenicity
  7. Evaluation of the abdominal wall and cord insertion site
  8. Identification and measurement of the stomach, kidneys, and urinary bladder
  9. Longitudinal and transverse imaging of the entire fetal spine to ensure integrity
  10. Assessment of all four extremities, including the presence of three segments and the orientation of hands and feet
  11. Determination of placental location, relationship to the cervix, and umbilical cord vessel count
  12. Measurement of amniotic fluid volume (AFV) or single deepest pocket

Coding Guidelines

  • Report 76811 for the first or single fetus; for additional fetuses in the same session, use add-on code +76812.
  • Code 76811 includes all the elements of a routine fetal survey (76805); therefore, 76805 and 76811 should not be reported together for the same patient on the same day.
  • 76811 is intended for a 'detailed' anatomic survey and should only be reported when all required components are visualized or the reason for non-visualization (e.g., fetal position) is documented.
  • This code should typically be reported only once per pregnancy unless there is a medically necessary reason for a repeat detailed evaluation.
  • If only a limited or follow-up ultrasound is performed after a detailed scan, use 76815 or 76816 instead of 76811.

Associated ICD-10 Codes