CPT 76815Radiology

Ob us limited fetus(s)

CPT code 76815 represents a limited ultrasound examination of a pregnant woman to assess specific aspects of the fetus, rather than a complete comprehensive ultrasound. This focused exam is used when only certain fetal structures or measurements need to be evaluated.

Showing rates for

National Average

Base Medicare rate

$78.28

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.65

PE RVU (NF)

1.73

MP RVU

0.04

Total RVU

2.42

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Clearly document the specific clinical question or limited indication that justifies 76815 rather than a comprehensive exam
Impact: Prevents automatic downcoding or denials for medical necessity; can prevent loss of entire $78.28 payment
Never bill 76815 on the same date as comprehensive obstetric ultrasounds (76805, 76811, 76816, 76817) for the same fetus without modifier 59 and distinct documentation
Impact: Bundling edits will deny 76815 as included; using modifier 59 inappropriately risks audit and recoupment
Document each fetal element examined with measurements and images; limited does not mean minimal documentation
Impact: Inadequate documentation can trigger medical review and potential denial of the full $78.28 reimbursement
For multiple gestations, bill 76815 separately for each fetus only when limited exam performed on each; append modifier 59 to second fetus
Impact: Proper multiple gestation billing can increase reimbursement to $156.56 for twins when medically justified
Verify that ordering diagnosis code supports limited rather than comprehensive exam (e.g., Z36 surveillance codes vs. specific fetal concerns)
Impact: Mismatched diagnosis codes trigger medical necessity denials; approximately 15-20% of 76815 denials are diagnosis-related
When performed in facility setting, ensure split billing is coordinated so both facility (TC) and physician (26) claim same units and dates
Impact: Mismatched claims result in denial of one component; coordination prevents loss of portion of $78.28

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Frequently asked questions

What is the difference between CPT 76815 and 76805?

CPT 76815 is a limited fetal ultrasound that examines specific fetal parameters or answers a discrete clinical question, while 76805 is a complete obstetric ultrasound that includes comprehensive fetal anatomic survey of all organ systems. The 2025 Medicare rate for 76815 is $78.28 compared to higher reimbursement for comprehensive exams. Use 76815 only when medical necessity supports a limited examination rather than complete anatomic evaluation.

How much does Medicare pay for CPT code 76815 in 2025?

The 2025 Medicare national average payment for CPT 76815 is $78.28 for both facility and non-facility settings. This is based on 2.42 total RVUs (0.65 work RVU, 1.73 PE RVU, 0.04 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Actual reimbursement may vary based on geographic locality adjustments.

Can you bill 76815 with 76805 on the same day?

Generally no, CPT 76815 and 76805 should not be billed together for the same fetus on the same date as they are bundled by NCCI edits. If truly medically necessary to perform both a limited and comprehensive exam for separate distinct indications, modifier 59 must be appended with extensive documentation justifying both examinations. Most payers will deny this combination without exceptional circumstances.

What diagnosis codes are appropriate for billing 76815?

Appropriate ICD-10 codes for 76815 include Z36.0-Z36.9 (antenatal screening and surveillance), O36 series (maternal care for known or suspected fetal problems), O40-O41 (polyhydramnios and oligohydramnios), and O32 series (fetal malpresentation). The diagnosis must support the medical necessity for a limited rather than comprehensive examination. Routine prenatal care codes alone may not justify the limited exam without additional clinical indication.

How many times can you bill 76815 during a pregnancy?

Medicare and most commercial payers do not impose a specific numerical limit on 76815, but each exam must be medically necessary with distinct clinical indication documented. Frequency should align with ACOG guidelines and clinical practice standards. Billing multiple limited exams in short succession without documented clinical changes or new indications will trigger medical review and potential denial.

Does CPT 76815 require modifier 26 in hospital settings?

Yes, when a physician performs only the interpretation in a hospital or facility setting, modifier 26 (professional component) must be appended to 76815. The facility bills the technical component with modifier TC. Without proper modifiers, the claim may be denied as duplicate billing or the physician may receive incorrect payment for global service when only interpretation was provided.

What are the documentation requirements for CPT 76815?

Documentation for 76815 must include the specific clinical indication for limited exam, description of fetal elements examined, measurements obtained, permanent recorded images, physician interpretation with signature, and clear statement that this is a limited examination. The medical record must justify why a limited rather than comprehensive exam was appropriate. Insufficient documentation is a leading cause of denials for this code.