Search all medical codes
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, 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, plus detailed fetal anatomic examination, transabdominal approach; each additional gestation
Summary
This is a specialized ultrasound procedure for pregnant women that involves a comprehensive evaluation of the fetus and mother. It includes real-time imaging and detailed anatomical examination of the fetus. The transabdominal approach is used, and it can be applied to each additional fetus in a multiple gestation pregnancy.
Purpose
- Medical Condition or Problem: Assessing the health and development of the fetus and the well-being of the mother.
- Goals: To ensure the proper development of the fetus, identify any potential complications early, and monitor the health of the mother and additional fetuses in multiple gestations.
Indications
- Symptoms such as abnormal fetal development indicators or pregnancy complications.
- Factors like multiple pregnancies or a history of complications in previous pregnancies.
Preparation
- Pre-Procedure Instructions: Generally, no special preparation is needed, but the patient may be advised to drink water to ensure a full bladder for a clearer ultrasound image.
- Diagnostic Tests: Previous ultrasound results and maternal health records may be reviewed.
Procedure Description
- The patient lies on an examination table.
- A gel is applied to the abdomen to facilitate better ultrasound transmission.
- A transducer (a handheld device) is moved over the abdomen to capture real-time images.
- Fetal and maternal evaluations are conducted, including anatomical examination.
- Images are documented for further analysis.
- For multiple gestations, the process is repeated for each additional fetus.
- Tools and Equipment: Ultrasound machine with a transabdominal transducer.
- Anesthesia: None required.
Duration
Typically takes around 30 to 60 minutes, depending on the number of fetuses and the complexity of the examination.
Setting
Performed in a hospital radiology department, outpatient clinic, or a specialized prenatal care center.
Personnel
- Radiologist or Obstetrician specialized in ultrasound.
- Sonographer (a technician trained in performing ultrasound exams).
- Occasionally, an obstetric nurse may assist.
Risks and Complications
- Common Risks: Minimal, as ultrasound is a safe and non-invasive procedure.
- Rare Complications: There are no known risks of harm to the mother or fetus from a standard ultrasound procedure.
- Management: Any discomfort can be managed on-site.
Benefits
- Detailed insight into fetal development and maternal health.
- Early detection of potential complications.
- Ability to monitor multiple fetuses effectively.
- Expected outcomes can usually be realized immediately after the examination.
Recovery
- Post-Procedure Care: No special care is needed.
- Recovery Time: Immediate, with no downtime.
- Follow-up: Additional appointments as recommended based on findings.
Alternatives
- Other Options: Limited due to the non-invasive and comprehensive nature of ultrasound.
- Pros and Cons: MRI may offer alternative imaging but is used less frequently due to cost and availability.
Patient Experience
- During the Procedure: Patients may feel some pressure from the transducer but should not experience pain.
- After the Procedure: Usually no discomfort.
- Pain Management: Not typically necessary, but comfort measures include a warm gel and a comfortable examination setting.