Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)
CPT4 code
Name of the Procedure:
Ultrasound, Pregnant Uterus, Real-time with Image Documentation, Fetal and Maternal Evaluation, After First Trimester (≥ 14 weeks 0 days), Transabdominal Approach; Each Additional Gestation
Summary
This procedure involves using an ultrasound machine to create real-time images of a pregnant uterus, focusing on both the fetus and the mother. It includes detailed evaluation after the first trimester of pregnancy. If there are multiple pregnancies (e.g., twins), each additional fetus is evaluated separately.
Purpose
The primary purpose of this ultrasound is to assess the health and development of the fetus and to monitor the mother's condition. It helps in:
- Checking fetal growth and development.
- Detecting multiple pregnancies.
- Monitoring the position of the fetus.
- Evaluating the amount of amniotic fluid.
- Examining the mother's uterus and placenta for any abnormalities.
Indications
- Routine prenatal check-up after 14 weeks of pregnancy.
- Confirmation and assessment of multiple pregnancies.
- Concerns about fetal growth or development.
- Monitoring high-risk pregnancies.
Preparation
- Typically, no special preparation is needed.
- The patient might be advised to have a full bladder to improve image clarity.
- No fasting or medication adjustments are generally required.
Procedure Description
- The patient lies on an examination table.
- A gel is applied to the abdomen to aid the transmission of sound waves.
- A transducer (handheld device) is moved over the abdomen to capture images.
- The healthcare provider views these images in real-time, documenting various aspects of the fetus and maternal structures.
- For multiple gestations, each fetus is evaluated separately.
Equipment used:
- Ultrasound machine
- Transducer
- Conductive gel
Typically, no anesthesia or sedation is needed.
Duration
The procedure usually takes 20 to 40 minutes, depending on the number of fetuses and the complexity of the exam.
Setting
Performed in a hospital, outpatient clinic, or specialized ultrasound facility.
Personnel
- A sonographer or ultrasound technician operates the ultrasound machine.
- An obstetrician, radiologist, or maternal-fetal medicine specialist may interpret the results.
Risks and Complications
- Ultrasound is generally considered safe with no known harmful effects.
- Rarely, there may be mild discomfort from the pressure of the transducer.
Benefits
- Provides critical information about fetal health and development.
- Helps in early detection of potential issues.
- Non-invasive and painless.
- Immediate results.
Recovery
- No recovery time is needed.
- The patient can resume normal activities immediately.
- Follow-up appointments as recommended by the healthcare provider.
Alternatives
- No direct alternatives provide the same real-time imaging and diagnostic capabilities.
- Some aspects of fetal health can be monitored through blood tests and other non-imaging assessments.
Patient Experience
- The patient might feel slight pressure from the transducer.
- Generally, it is a painless and quick procedure.
- Comfort measures such as adjusting the position can be made to ensure the patient feels at ease.
This procedure provides essential insights into the health of both the fetus and the mother, making it a vital tool in prenatal care, especially for those with multiple pregnancies.