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76856

Complete Pelvic Ultrasound

Code Description

CPT code 76856 is used to report a complete non-obstetric ultrasound examination of the pelvis. The examination uses real-time ultrasound imaging with image documentation to evaluate pelvic anatomy.

In female patients, a pelvic ultrasound may evaluate structures including the uterus, endometrium, ovaries, adnexal structures, and bladder. In male patients, the examination may evaluate structures including the bladder, prostate, and seminal vesicles.

When to Use 76856

Common examples include:

  • Pelvic pain

  • Abnormal uterine bleeding

  • Suspected ovarian cyst

  • Evaluation of a pelvic mass

  • Uterine abnormalities

  • Prostate or bladder evaluation

  • Follow-up of known pelvic abnormalities

Documentation Requirements

Documentation should include:

  • Reason for the examination

  • Complete pelvic examination performed

  • Anatomical structures evaluated

  • Relevant symptoms or diagnosis

  • Image documentation

  • Physician or radiologist interpretation

  • Diagnostic findings

Common Billing Mistakes

Common billing mistakes include:

  • Reporting 76856 for a limited pelvic ultrasound

  • Confusing non-obstetric and obstetric ultrasound codes

  • Failing to document a complete examination

  • Confusing transabdominal and transvaginal ultrasound services

  • Incorrect use of Modifier 26 or TC

Related CPT Codes
76700

Complete Abdominal Ultrasound

77002

Fluoroscopic Guidance

77012

CT Guidance

FAQ

What does CPT code 76856 cover?

CPT code 76856 reports a complete non-obstetric ultrasound examination of the pelvis with real-time imaging and image documentation.

Is CPT 76856 an obstetric ultrasound code?

No. CPT 76856 is used for a non-obstetric complete pelvic ultrasound examination. Obstetric ultrasound services are reported with different CPT codes.

What is the difference between CPT 76856 and 76857?

CPT 76856 reports a complete pelvic ultrasound examination, while CPT 76857 is used for a limited pelvic ultrasound study.

Is CPT 76856 the same as a transvaginal ultrasound?

No. CPT 76856 represents a complete non-obstetric pelvic ultrasound, while transvaginal ultrasound is reported separately with CPT 76830 when the service and documentation requirements are met.

Procedure Type

Diagnostic Ultrasound

Body Area

Exam Type

Pelvis

Complete, Non-Obstetric