Payment Policy: Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Reference Number: CC.PP.061
Last Review Date: 07/2025

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Policy Overview

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds
A non-obstetrical or first trimester obstetrical transabdominal ultrasound may be performed during the same patient encounter as a transvaginal ultrasound when medically necessary. When both procedures are reported for the same patient, on the same day, the health plan will reimburse the primary procedure (transvaginal ultrasound) at 100% of the fee schedule allowed amount and apply a multiple procedure payment reduction of 50% to the secondary procedure (transabdominal ultrasound).

Application
Office Setting
Institutional and Non-institutional Settings
Professional Claims

Policy Description
The health plan supports the Centers for Medicare and Medicaid Services (CMS) guidelines that multiple procedure payment reductions apply when multiple services are furnished by the same physician or same group physician/other health care professional, during a single patient encounter.

When a provider performs a non-obstetrical or first trimester obstetrical transabdominal ultrasound along with a transvaginal ultrasound during a single patient encounter, most of the clinical labor activities are neither performed nor furnished twice. Provider reimbursement for a procedure code includes reimbursement for clinical labor costs associated with that service. The following clinical labor activities are some examples of activities that are not duplicated for subsequent procedures:

• Greeting the patient
• Gowning the patient
• Preparing and cleaning the room
• Positioning and escorting the patient
• Providing education and obtaining consent
• Retrieving prior examinations

It is the policy of the Plan to apply a multiple procedure payment reduction to adjust provider reimbursement to offset duplication of clinical labor activities that were only rendered once.

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PAYMENT POLICY

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Reimbursement

Non Obstetrical Transabdominal Ultrasound Billed with Transvaginal Ultrasound
CPT code 76856 represents a non-obstetrical transabdominal ultrasound, real time with image documentation; complete. CPT code 76830 represents a non-obstetrical transvaginal ultrasound.

First Trimester Obstetrical Transabdominal Ultrasound Billed with Transvaginal Ultrasound
CPT code 76801 describes an ultrasound, pregnant uterus, real time image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach, single or first gestation. CPT code 76817 represents an ultrasound, pregnant uterus, real time with image documentation, transvaginal.

During the course of a single patient encounter, if a provider performs a non-obstetrical or first trimester obstetrical transabdominal ultrasound and determines that the image is unclear and that a transvaginal ultrasound is necessary; only the transvaginal ultrasound will be reimbursed at 100% of the paid amount allowance. The transabdominal ultrasound will be reimbursed at 50% of the paid amount allowance.

Coding and Modifier Information
This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2025, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

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PAYMENT POLICY

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Definitions

Transvaginal Ultrasound: A transvaginal ultrasound is a type of abdominal ultrasound used by doctors to examine female reproductive organs. This includes the uterus, fallopian tubes, ovaries, cervix, and vagina. “Transvaginal” means “through the vagina.” This is an internal examination.

Transabdominal Ultrasound: A Transabdominal ultrasound is a noninvasive diagnostic exam that produces images that are used to assess organs and structures within the female pelvis. A Transabdominal ultrasound allows quick visualization of the female Transabdominal organs and structures including the uterus, cervix, vagina, fallopian tubes and ovaries. The transducer is pressed firmly against the skin and swept back and forth over the lower abdomen and images are obtained of the uterus, ovaries, and surrounding Transabdominal structures. This is an external examination.

Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number

Non-Obstetrical: Not related to the pregnancy, childbirth nor postpartum period.

Physicians within the Same Group Practice; Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

Related Documents or Resources
CP.MP.38, “Ultrasound in Pregnancy”

| 01/10/2023 | Conducted annual review. Updated copyright dates. Updated Policy Description. |

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PAYMENT POLICY

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Important Reminder
For the purposes of this payment policy, “Health Plan” means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan’s affiliates, as applicable.

The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as state and federal requirements and applicable plan-level administrative policies and procedures.

This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time.

This payment policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This payment policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan.

This payment policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services.

Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence.

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PAYMENT POLICY

Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds

Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy.

Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at http://www.cms.gov for additional information.

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