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Awesome tips for Biophysical profile coding

Fetal biophysical profile score (BPS or BPP) refers to assessment of four discrete biophysical variables by ultrasound. It is often a standard tool in antepartum fetal assessment. It is usually  assessed after 28 weeks of gestation. The BPP combines data from two machines, ultrasonographic imaging and fetal heart rate [FHR] monitoring.

The ultrasound variables include

•         Fetal breathing
•         Fetal tone
•         Fetal movement (gross body movement)
•         Amniotic fluid volume
 Each of these parameters is given a score of either 0 or 2 points where an abnormal score gets 0 while a normal score gets 2.

Therefore, on ultrasound assessment, a total score is given out of 8. An overall abnormal score out of 8 is often taken as 4/8 or less.

Awesome tips for Biophysical profile coding

Biophysical profile CPT Codes

We have two CPT Codes used for coding Biophysical Profile. The procedure is done with non-stress and without non-stress. Following are the two CPT codes are used for Biophysical profile.

76818- Fetal biophysical profile; with non-stress testing

76819- Fetal Biophysical Profile; without Non-stress testing

The CPT codes can be used again depending on the number of fetus.

Criteria for Coding biophysical profile codes

If biophysical profile assessments are done on multiple fetuses, report 76818 or76819 separately as appropriate for each fetus after the first and append modifier 59 or an X{EPSU} modifier to additional codes. For example, if we have twins A and B and physician performs Biophysical profile procedure on both. Then any one of the cpt will have 59 or X {EPSU} modifier to bill both the procedure. So, the final code will be

A-76819 and B-76819-59 or X {EPSU}

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A-76818 and B-76818-59 or X {EPSU}

Sample Report for Biophysical Profile

US FETAL BIOPHYSICAL PROFILE WO NON STRESS

CPT 76819    

INDICATION: oligohydramnios

US FETAL BIOPHYSICAL PROFILE WO NON STRESS

HISTORY: Oligohydramnios – BPP

TECHNIQUE/SCAN QUALITY

FETAL EVALUATION Num Of Fetuses: 1 Preg.

Location: Intrauterine Fetal Pole:

Visualized Fetal Heart Rate: 139 bpm

Cardiac Activity: Visualized.

Presentation:Cephalic

 Placenta: Anterior. No previa.

Amniotic Fluid AFI FV:

Oligohydramnios AFI Sum: 6.77 cm

4 % Tile

Larg Pckt: 3.55 cm

RUQ: 2.26 cm

LUQ: 0.0 cm

RLQ: 3.55 cm

LLQ: 0.96 cm

BIOPHYSICAL EVALUATION Amniotic F.

V: Pocket => 2 cm two F.

Tone: Observed

planes F.

Movement: Observed

Score: 8/8 F.

Breathing: Observed

BIOMETRY

GESTATIONAL AGE Clinical EDD: 38 w 2 d

EDD: 02/09/15

Best: 38 w 2 d

Det.

By: Clinical EDD

EDD: 02/09/15

IMPRESSION: Normal biophysical profile with score of 8/8. Oligohydramnios. AFI measures 6.77 cm, previously 9.9 cm.

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