CPT Knowledgebase - Nov 27, 2007

A transvaginal ultrasound for follicular measurements is performed and reported with 76857 as it is a limited assessment of one or more elements. The sizes of follicles are written down (including whether right or left side) on an IVF flow sheet. CPT guidelines for non-obstetrical ultrasounds state "Use of ultrasound without thorough evaluation of the organ(s) or anatomic region, image documentation and final, written report, is not separately reportable." Based upon the above example, would the sizes of the follicles be considered image documentation? Or does image documentation mean that a photograph of the adnexa needs to be taken and stored for every follicle or for every ultrasound. What does image documentation consist of?

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