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Available online at www.sciencedirect.com

www.elsevier.com/locate/semperi

Obstetric ultrasound terminology

Joshua A. Copel, MD
Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, 333 Cedar St, PO Box 208063, New Haven, CT 06520-8063

ART IC LE INFO

AB ST R A CT
Obstetric ultrasound terminology currently varies between CPT book terminology and

Keywords: Ultrasound Coding CPT Obstetric scan

society guidelines. The major medical societies representing practitioners in this area have worked together to provide consistent guidelines for their members, in the interest of highquality patient care. & 2013 Elsevier Inc. All rights reserved.

Practically speaking, the terminology used for describing obstetric ultrasound scans is drawn from medical society guidelines13 and from descriptions in the Current Procedural Terminology (CPT) book of the American Medical Association.4 When initial efforts to create professional guidelines arose, the leadership of ACOG, ACR, and AIUM had the vision to recognize that major differences in the content of guidelines between organizations could lead to a number of undesirable outcomes. The most important concept bringing the societies together was quality of patient care: regardless of who performs an obstetric ultrasound, the content should be the same. It also made sense to have similar guidelines to avoid any situation where practitioners might encounter liability for following one society's guideline rather than another's. The content of the examinations is intended to be identical in the documents from each of the three societies, although each presents the information in a slightly different format, and with different accompanying information. The ACR-ACOG-AIUM guidelines dene several types of obstetric scan, termed rst trimester, limited, standard second, or third trimester, and specialized examinations. These guidelines were then reviewed and endorsed by SMFM. Unfortunately, there are different terms used in the professional society guidelines and in the CPT, although there is some rough correlation between terms. The societal guidelines include indications for imaging as well as descriptions of content. In the interest of brevity, the indications portions will not be reviewed in detail here. The guidelines are

available for free download at http://www.aium.org and at http://www.acr.org. The intent of rst trimester examination seems clear on the surface, although there are varying denitions of the rst trimester. The rst third of a 40-week pregnancy would last from 013 weeks 2 days, while common usage includes the rst 12 weeks in the rst trimester. The CPT denition of rst trimester scan (CPT 76801) is o14 weeks 0 days, perhaps in keeping with considering each trimester to be 14 weeks, since 14 is one-third of 42 weeks. The society guideline content of the rst trimester scan includes evaluation of the uterus, including the cervix, and adnexa for the presence of a gestational sac, whose location should be documented if present, as well as evaluation for the presence or absence of a yolk sac or embryo, and recording of the crown-rump length. It also includes a record of the fetal number, as well as evaluation of the uterus, cervix, adnexa, and cul de sac, and embryonic/fetal anatomy as appropriate for the rst trimester. The CPT book has slightly different wording for the 76801 scan, specifying determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestationsurvey of visible fetal and placental anatomic structure, qualitative assessment of amniotic uid volume/gestational sac shape and examination of maternal uterus and adnexa. The limited examination is designed to answer a specic clinical question (e.g. whether the fetus is breech or vertex, or to verify the presence of fetal cardiac activity). This can also

E-mail address: joshua.copel@yale.edu 0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2013.06.018

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be used as part of fetal testing when the limited biophysical prole, consisting of the NST and a uid check, is often the test of choice. All denitions are consistent on this, including the CPT, which goes beyond the AIUM/ACOG/ACR documents to specify that the code (76815) should be used only once per examination and not per element, and that the code is used only once whether there are one or more fetuses. Although AIUM has a statement on limited obstetrical ultrasound, it contains a disclaimer specically disavowing any intent to dene the examination for coding and billing purposes.5 The joint societal guidelines address the standard obstetric scan and specialized examinations. The conditions for the standard obstetric scan are not described beyond the extensive list of indications in the documents. The specialized examination is performed when an anomaly is suspected on the basis of history, biochemical abnormalities, or the results of either the limited or standard scan. Other forms of specialized examination might include fetal Doppler sonography, biophysical prole, a fetal echocardiogram, or additional biometric measurements. The terminology for these different scans has been confusing for years. The original terminology arose from the early days of maternal serum alpha-fetoprotein (MSAFP) screening, when an abnormally high MSAFP prompted an initial sonogram (Level 1 scan) to conrm dates and fetal life, and to exclude twins, ndings which could cause a higher than expected MSAFP. This scan was thought to be simple and essentially a screening examination that would explain the abnormal value in most cases (usually incorrect dates in the days before wide availability of rst trimester ultrasound). If that scan did not provide an explanation for the abnormal MSAFP, the patient would be referred to a consultant practice for a second scan (Level 2). As image quality improved, we became able to make more diagnoses with ultrasound but the terminology remains unchanged in many parts of the country. Other terms also arose, such as genetic sonogram, targeted scan, and fetal survey, and we have all experienced referrals for a Level-3 scan. In fact, in the Ask the Experts section of FitPregnancy.com it says The American College of Obstetricians and Gynecologists recommends that all pregnant women be offered a diagnostic, or Level-3, ultrasound (http://www.tpregnancy.com/pregnancy/ level-3-ultrasounds Accessed July 5, 2013), which is certainly not consistent with any past or present ACOG position. So, we have at least three sets of terminology for these more comprehensive scans. In the societal guidelines, they are called specialized examinations as well as detailed or targeted anatomic examinations. In the CPT book, we have the 76811 code, which refers to a detailed fetal anatomic examination. Finally, colloquially we have a variety of terms that are often regional or institution-specic, and at best vague in meaning.

The major issues regarding the specialized exam relate to when it should be performed and what qualications are required to perform it. Those preparing the original application to CPT for a specialized exam conceived of it as an exam that would be used only for indication suggesting a heightened risk of fetal anomalies, which is not as a routine for all scans performed by any group (ie MFMs). It was also intended for use by any practitioner with the necessary advanced training to provide comprehensive diagnostic and counseling services to the gravida. So, while some general Obstetricians might possess that experience, this was anticipated to be uncommon, with most exams performed by consultant sonologists, who might be MFMs or Radiologists with special interest in fetal imaging. A nal question, and perhaps a moving target, is when to perform the specialized examination. The usual time is at about 18-weeks gestation, to balance issues of visualization with maintaining pregnancy options. Some advocate earlier examinations, even at 1215 weeks with reliance on transvaginal as well as abdominal sonography.

Recommendations

   

Make denitions concordant between CPT book Societal guidelines Introduce consistent terminology communication

for

clarity

in

Promote nationally accepted recommendations for indications for scans, utilization of 76811 code Develop consensus on handling of earlier anatomy scans

re fe r en ces

1. American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med. 2010;29(1):157166. 2 American College of Obstetricians and Gynecologists. Ultrasonography in Pregnancy. ACOG Practice Bulletin No. 101. Obstet Gynecol. 2009;113(2 Pt 1):451 461. 3. Radiology ACo. ACR-ACOG-AIUM practice guideline for the performance of obstetrical ultrasound. http://www.acr.org/ Quality-Safety/Standards-Guidelines/Practice-Guidelines-byModality/Ultrasound; 2007. 4. Association AM. Current procedural terminology. Chicago: American Medical Association. http://www.gpo.gov/fdsys/ pkg/FR-2010-06-25/html/2010-15416.htm; 2012. 5. Medicine AIoUi. Limited obstetrical ultrasound. http://www. aium.org/resources/statements.aspx; 2009 (11/17/12).