Limited Reproductive Endocrinology and Infertility (REI) Ultrasound Examination

A limited ultrasound examination is a focused evaluation performed to answer a specific clinical question or concern. A limited REI ultrasound examination may be performed in a patient who is undergoing serial ultrasound examinations to monitor follicle size and endometrial thickness.  

The imaging is limited to the areas required to answer a specific clinical question and is driven by the clinical history and physical exam as described by the referring provider and guided by the expertise and experience of the interpreting clinician.

A limited ultrasound examination does not include a comprehensive evaluation of pelvic anatomy but assumes that a complete female pelvic survey has been done or will be performed later in the index treatment cycle. The patient should be informed that the study is limited and only seeking to answer a specific clinical question.

A complete examination (CPT code 76830) is a more thorough and comprehensive REI study. However, in acute situations, or to provide only focused information, a limited examination (CPT code 76857) may be the more appropriate study. The type of examination ordered and/or performed is based on the clinical judgement and expertise of the referring and interpreting clinician.

Documentation for a limited REI ultrasound examination should comply with the AIUM Practice Parameter for Documentation of an Ultrasound Examination and include retention of images and a final report of the findings.

Providers should meet the appropriate AIUM training guideline. Physicians should conform to the Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Obstetrical Ultrasound Examinations. Advanced Clinical Providers should conform to the AIUM Training Guidelines for Licensed Medical Providers (PA, NP, CNM/CM, DPT, and DC) Who Perform and/or Interpret Diagnostic Ultrasound Examinations and have a complete understanding of their scope of practice within the state where they practice.

Diagnostic ultrasound should be performed only when there is a valid medical indication, using the lowest possible ultrasonic exposure setting to gain the necessary diagnostic information on under the ALARA (As Low As Reasonably Achievable) principle. The Output Display Standard, an on-screen real-time display of acoustic output, should be visible and monitored for Thermal and Mechanical Index.

Dwell time should be kept to a minimum.

This document is not intended to provide a formal definition of a limited ultrasound for billing or coding purposes.