When is a pelvic ultrasound (or sonogram) recommended?

Indications for pelvic sonogram to evaluate uterus and ovaries

• Painful sex
• Pelvic pain, low back pain
• Irregular bleeding or heavy bleeding
• IUCD placement check
• Delayed periods
• Ovarian cysts, uterine fibroids
• Rule out pregnancy
• Obesity/abdominal bloating – unable to evaluate uterus on exam
• Urinary incontinence
• Pelvic inflammatory disease
• Congenital abnormalities of genital tract (uterus/ovaries)

What is included in a pelvic ultrasound and what are the codes associated with these studies?

Pelvic ultrasound is a two‑part study as listed below. Both parts are important to complete a full evaluation of the pelvic organs.

1) Pelvic abdominal ultrasound

CPT 76856. This is part one of the pelvic ultrasound which includes visualization of the lower abdomen from the lower part of the abdomen and includes evaluation of uterus/bladder and any other additional masses (if present) from the lower abdominal angle.

2) Pelvic transvaginal ultrasound

CPT 76830. This is the second component of the pelvic ultrasound. In this study, a vaginal probe is used to evaluate the uterus/ovaries/adnexal masses from the vagina.

Both the above studies are needed for a full pelvic evaluation and are often indicated by a separate CPT code. They evaluate the pelvis via two separate studies with different probes.

Situations in which we may not do a Transvaginal sonogram

• If you have never had vaginal intercourse (virgin).
• If you are actively bleeding from the vagina.
• If you are pregnant and have placenta previa.

What is a 3D Ultrasound?

3D ultrasound (CPT 76377) is done in addition if there are any masses, fibroids, IUD, or any uterine pathology. It looks at a structure with a specialized setting from all directions so that we can evaluate that structure with more accuracy. This requires a very advanced probe and setting, hence a different code.

What is a color doppler and why was it done?

A color Doppler (CPT 93975) is done in addition if there is pelvic pain/ovarian cyst/mass/tumor etc. Essentially, color Doppler looks for blood flow in and around the organ. This study is important in many cases to evaluate if the mass could be cancerous, or if there is an ectopic pregnancy or something else that “shouldn’t be there.” It also helps us evaluate the risk of torsion (twisting) or suspected ovarian torsion which, if not treated early, can lead to permanent ovarian damage.

Does a pelvic ultrasound also check for my liver and gall bladder?

No. For that you need a complete abdominal ultrasound (CPT 76700–76702) which includes a full exam of your upper and mid abdomen and organs such as gall bladder/liver/stomach etc. We do not perform this study at our facility since we are a GYN (women’s health) facility.

I thought ultrasound was included in my annual and it’s free!

Ultrasound is never considered preventative by your insurance. We agree that it is an important screening test but it’s not covered as “free” under your annual visit. Your out‑of‑pocket costs will apply to this diagnostic service. We didn’t make these rules. If you have questions regarding coverage and cost of pelvic sonos, please feel free to call your insurance before scheduling your appointment.

Hope this helps clarify your concerns. We are happy to give you a secure link with all the images and also a finalized report. Please note that the finalized report can take up to 10 days.

Sincerely,
Westside New York Medical PC Team.