76805

Ultrasound, pregnant uterus, transabdominal, evaluation of fetus and mother, single or first gestation, after first trimester

CPT 76805 describes a comprehensive transabdominal ultrasound examination of a pregnant uterus when the gestational age is 14 weeks 0 days or greater. This procedure is commonly referred to as a standard or routine second-trimester fetal anatomical survey. The primary objective of this diagnostic imaging is to provide a thorough evaluation of fetal growth, development, and well-being, while also assessing key maternal structures. During the procedure, the sonographer or physician evaluates several critical fetal components, including the head (intracranial structures like the ventricles, cerebellum, and cisterna magna), the face, the spine, the thorax (including a four-chamber view of the heart), the abdomen (stomach, kidneys, and bladder), and the extremities. Biometric measurements are essential and typically include the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL). These measurements are used collectively to estimate fetal weight and confirm or adjust gestational age. In addition to fetal anatomy, the examination must document the number of fetuses, fetal lie (position), and fetal heart rate or activity. Maternal components of the exam include an assessment of the placenta's location and its relationship to the internal cervical os, the volume of amniotic fluid (subjective or measured), and the survey of the maternal adnexa and cervix if visualized. This code is designated for a single gestation or the first gestation in a multiple-fetus pregnancy; for each additional fetus, the add-on code 76810 must be reported in conjunction with 76805. It serves as a baseline for monitoring and is vital for identifying potential anomalies or complications that may necessitate a more detailed fetal ultrasound (76811) or maternal-fetal medicine consultation.

Clinical Indications

  • Routine screening for fetal anomalies in the second or third trimester
  • Estimation of gestational age and fetal weight
  • Evaluation of fetal growth (e.g., suspected intrauterine growth restriction or macrosomia)
  • Localization of the placenta (e.g., suspected placenta previa)
  • Assessment of amniotic fluid volume (e.g., suspected oligohydramnios or polyhydramnios)
  • Evaluation of pelvic pain or vaginal bleeding during pregnancy
  • Follow-up of an abnormality found on a previous scan
  • Assessment of fetal presentation or lie
  • Evaluation of maternal adnexal masses or uterine leiomyomata

Procedure Steps

  1. Confirm patient identity and obtain relevant clinical history (LMP, previous scans).
  2. Position the patient in a supine or semi-recumbent position with the abdomen exposed.
  3. Apply acoustic coupling gel to the maternal abdomen to ensure optimal transducer contact.
  4. Utilize a curvilinear or phased array transducer to scan the uterus in multiple planes (longitudinal, transverse, and oblique).
  5. Identify the number of fetuses and confirm fetal cardiac activity.
  6. Perform fetal biometry, including measurements of BPD, HC, AC, and FL.
  7. Conduct a systematic anatomical survey of the fetal head, spine, heart, thorax, abdomen, and limbs.
  8. Determine placental location and assess for any signs of abruption or previa.
  9. Evaluate the volume of amniotic fluid, documenting as normal, increased, or decreased.
  10. Visualize and assess the maternal cervix and adnexa where possible.
  11. Capture and archive representative images of all required anatomical structures and measurements.
  12. Complete a formal written report documenting all findings, measurements, and conclusions.

Coding Guidelines

  • Use 76805 for a single gestation or the first fetus of a multiple gestation pregnancy occurring at or after 14 weeks 0 days.
  • For multiple gestations, report 76805 for the first fetus and use add-on code 76810 for each additional fetus.
  • Do not report 76805 in conjunction with 76811 (Detailed fetal anatomic examination); 76811 is a more intensive service performed for specific indications.
  • If a transvaginal ultrasound is performed at the same session to better visualize the cervix or placenta, report 76817 in addition to 76805.
  • Code 76805 includes all components of a standard ultrasound; if only a limited portion is performed (e.g., just heart rate or just fluid), use 76815 instead.
  • A formal written report and the maintenance of image documentation (either physical or electronic) are required to bill this code.
  • For pregnancies less than 14 weeks 0 days, use codes 76801 and 76802 instead.

Associated ICD-10 Codes