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Guidance for coding limited or follow-up ultrasounds used during an IVF Cycle


I am a coder for a Reproductive Endocrinologist's office and am looking for some guidelines on limited or follow-up ultrasounds used during an IVF Cycle. The provider currently documents the type of ultrasound and how it is performed, always transvaginal.  In our current EMR, Epic, I am able to see an REI Concise cycle detailed snapshot.  This includes but is not limited to follicle counts, lab results, and endometrial strip measurements. The ultrasound images are also uploaded to the patient's chart, which includes measurements directly on images. The providers will note if something unusual or out of the ordinary is found as well as the plan moving forward when appropriate.

During ultrasound for follicle checks, does an image need to be saved to a chart? Are there documentation and image requirements for this type of service?



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