CPT Code for Transvaginal Ultrasound for Endometrial Hyperplasia
The CPT code for transvaginal ultrasound to evaluate endometrial hyperplasia is 76830 (Ultrasound, transvaginal).
Primary CPT Code
- CPT 76830 is the standard code for transvaginal ultrasound examination of the uterus and adnexa, which includes evaluation of the endometrium for suspected hyperplasia 1, 2
- This code encompasses measurement of endometrial thickness, assessment of endometrial echogenicity, and evaluation of the endometrial-myometrial interface 3
Additional CPT Codes That May Apply
- CPT 76831 may be used if a more comprehensive transvaginal ultrasound is performed with detailed evaluation of the uterus, adnexa, and surrounding structures 4
- CPT 76817 (Ultrasound, pregnant uterus, real time with image documentation, transvaginal) should NOT be used for endometrial hyperplasia evaluation, as this is specific to obstetric indications
- CPT 76830 with modifier 26 if only the professional component (interpretation) is being billed separately from the technical component
When Combined Procedures Are Performed
- If both transabdominal and transvaginal ultrasound are performed together (which is recommended practice), both CPT 76856 (pelvic ultrasound, complete) and 76830 may be billed, as the American College of Radiology considers these complementary procedures 4
- CPT 58340 (saline infusion sonohysterography) is a separate procedure code if sonohysterography is performed to further characterize a focal endometrial abnormality identified on initial transvaginal ultrasound 4, 1
Documentation Requirements for Proper Coding
- The ultrasound report must document endometrial thickness measurement (double-layer thickness at the thickest portion), endometrial echogenicity, contour regularity, and presence of any focal lesions 3
- Color Doppler evaluation of endometrial vascularity, while considered standard practice by ACR, is typically included in CPT 76830 and does not require separate coding 4
- The indication for the study (abnormal uterine bleeding, suspected endometrial hyperplasia, postmenopausal bleeding) should be clearly documented with appropriate ICD-10 codes 1
Common Coding Pitfalls to Avoid
- Do not use obstetric ultrasound codes (76801-76817 series) for gynecologic indications like endometrial hyperplasia
- Ensure that if both transabdominal and transvaginal approaches are used, both are documented in the report to justify billing both codes 4
- Doppler evaluation is considered an integral component of pelvic ultrasound and should not be separately coded unless specifically requested as a standalone study 4