Clinical UM Guideline


Subject:  Maternity Ultrasound in the Outpatient Setting
Guideline #:  CG-MED-42Current Effective Date:  04/15/2014
Status:RevisedLast Review Date:  02/13/2014

Description

Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images of internal organs by sending high-frequency sound waves into the body. The sound wave echoes are recorded and displayed as a real-time visual image. No ionizing radiation (x-ray) is involved in ultrasound imaging. Ultrasound during pregnancy is used to assess the uterus, umbilical cord and placenta, as well as fetal anatomy and well being. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. This document does not address nuchal translucency.

Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

Maternity ultrasound is considered medically necessary for any of the following:

Not Medically Necessary:

Maternity ultrasound is considered not medically necessary for:

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
76801Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; single or first gestation
76802Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; each additional gestation
76805Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; single or first gestation
76810Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; each additional gestation
76811-76812Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach
76815Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
76816Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus
76817Ultrasound, pregnant uterus, real time with image documentation, transvaginal
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
630-631Hydatidiform mole
632Missed abortion
633.00-633.91Ectopic pregnancy
634.00-634.92Spontaneous abortion
635.00-635.92Legally induced abortion
640.03-640.93Hemorrhage in early pregnancy, antepartum condition or complication [includes codes 640.03, 640.83, 640.93]
641.03-641.93Antepartum hemorrhage, abruption placentae, and placenta previa, antepartum condition or complication [includes codes 641.03, 641.13, 641.23, 641.33, 641.83, 641.93]
642.03-642.93Hypertension complicating pregnancy, childbirth, and the puerperium [includes codes 642.03, 642.13, 642.23, 642.33, 642.43, 642.53, 642.63, 642.73, 642.93]
643.03-643.93Excessive vomiting in pregnancy, antepartum condition or complication [includes codes 643.03, 643.13, 643.23, 643.83, 643.93]
644.03Threatened premature labor, antepartum condition or complication
646.33Recurrent pregnancy loss, antepartum condition or complication
646.83Other specified complications of pregnancy, antepartum condition or complication
646.93Unspecified complication of pregnancy, antepartum condition or complication
647.63Other viral diseases complicating pregnancy, antepartum condition or complication
648.03Diabetes mellitus complicating pregnancy, antepartum condition or complication
648.23Anemia complicating pregnancy, antepartum condition or complication
648.33Drug dependence complicating pregnancy, antepartum condition or complication
648.43Mental disorders complicating pregnancy, antepartum condition or complication
648.83Abnormal glucose tolerance complicating pregnancy, antepartum condition or complication
648.93Other current conditions classifiable elsewhere, complicating pregnancy, antepartum condition or complication
649.53Spotting complicating pregnancy, antepartum condition or complication
649.63Uterine size date discrepancy, antepartum condition or complication
651.03Twin pregnancy, antepartum condition or complication
651.13Triplet pregnancy, antepartum condition or complication
651.23Quadruplet pregnancy, antepartum condition or complication
651.83Other specified multiple gestation, antepartum condition or complication
651.93Unspecified multiple gestation, antepartum condition or complication
652.03-652.93Malposition and malpresentation of fetus, antepartum condition or complication [includes codes 652.03, 652.13, 652.23, 652.33, 652.43, 652.53, 652.63, 652.73, 652.83, 652.93]
654.03Congenital abnormalities of uterus, antepartum condition or complication
654.13Tumors of body of uterus, antepartum condition or complication
654.33Retroverted and incarcerated gravid uterus, antepartum condition or complication
654.43Other abnormalities in shape or position of gravid uterus and of neighboring structures, antepartum condition or complication
654.53Cervical incompetence, antepartum condition or complication
654.63Other congenital or acquired abnormality of cervix, antepartum condition or complication
655.03-655.93Known or suspected fetal abnormality affecting management of mother, antepartum condition or complication [includes codes 655.03, 655.13, 655.23, 655.33, 655.43, 655.53, 655.63, 655.73, 655.83, 655.93]
656.13Rhesus isoimmunization, antepartum condition or complication
656.43Intrauterine death, antepartum condition or complication
656.53Poor fetal growth, antepartum condition or complication
656.63Excessive fetal growth, antepartum condition or complication
656.73Other placental conditions, antepartum condition or complication
656.83Other specified fetal and placental problems, antepartum condition or complication
656.93Unspecified fetal and placental problem, antepartum condition or complication
657.03Polyhydramnios, antepartum condition or complication
658.03Oligohydramnios, antepartum condition or complication
658.13Premature rupture of membranes, antepartum condition or complication
658.23Delayed delivery after spontaneous or unspecified rupture of membranes, antepartum condition or complication
659.73Abnormality in fetal heart rate or rhythm, antepartum condition or complication
663.03-663.93Umbilical cord complications, antepartum condition or complication [includes codes 663.03, 663.13, 663.23, 663.33, 663.43, 663.53, 663.63, 663.83, 663.93]
667.04Retained placenta without hemorrhage, postpartum condition or complication
667.14Retained portions of placenta or membranes without hemorrhage, postpartum condition or complication
678.03Fetal hematologic conditions, antepartum condition or complication
678.13Fetal conjoined twins, antepartum condition or complication
789.03-789.04Abdominal pain, right/left lower quadrant
V19.5Family history of congenital anomalies
V22.0-V22.2Supervision of normal pregnancy [codes 76801, 76805, when criteria are met]
V23.1Supervision of pregnancy with history of trophoblastic disease
V23.2Supervision of pregnancy with history of abortion
V23.41-V23.49Supervision of pregnancy with other poor obstetric history
V23.5Supervision of pregnancy with other poor reproductive history
V23.7Supervision of pregnancy with insufficient prenatal care
V23.81-V23.82Supervision of other high-risk pregnancy, elderly primigravida/multigravida
V23.89-V23.9Supervision of other/unspecified high-risk pregnancy,
V25.42Intrauterine contraceptive device
V28.4Screening for fetal growth retardation using ultrasonics
V28.82Encounter for screening for risk of pre-term labor
V91.00-V91.99Multiple gestation placenta status
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
O00.0-O00.9Ectopic pregnancy
O01.0-O01.9Hydatidiform mole
O02.0-O02.9Other abnormal products of conception
O03.4Incomplete spontaneous abortion without complication
O03.9Complete or unspecified spontaneous abortion without complication
O07.4Failed attempted termination of pregnancy without complication
O09.10-O09.13Supervision of pregnancy with history of ectopic or molar pregnancy
O09.211-O09.219Supervision of pregnancy with history of pre-term labor
O09.291-O09.299Supervision of pregnancy with other poor reproductive or obstetric history
O09.30-O09.33Supervision of pregnancy with insufficient antenatal care
O09.511-O09.529Supervision of elderly primigravida and multigravida
O09.891-O09.93Supervision of other or unspecified high risk pregnancy
O10.011-O10.019Pre-existing essential hypertension complicating pregnancy
O10.111-O10.119Pre-existing hypertensive heart disease complicating pregnancy
O10.211-O10.219Pre-existing hypertensive chronic kidney disease complicating pregnancy
O10.311-O10.319Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy
O10.411-O10.419Pre-existing secondary hypertension complicating pregnancy
O10.911-O10.919Unspecified pre-existing hypertension complicating pregnancy
O11.1-O11.9Pre-existing hypertension with pre-eclampsia
O14.00-O14.93Pre-eclampsia
O16.1-O16.9Unspecified maternal hypertension
O20.0-O20.9Hemorrhage in early pregnancy
O21.0-O21.9Excessive vomiting in pregnancy
O24.011-O24.019Pre-existing diabetes mellitus, type 1, in pregnancy
O24.111-O24.119Pre-existing diabetes mellitus, type 2, in pregnancy
O24.311-O24.319Unspecified pre-existing diabetes mellitus in pregnancy
O24.410-O24.419Gestational diabetes mellitus in pregnancy
O24.811-O24.819Other pre-existing diabetes mellitus in pregnancy
O24.911-O24.919Unspecified diabetes mellitus in pregnancy
O26.20-O26.23Pregnancy care for patient with recurrent pregnancy loss
O26.30-O26.33Retained intrauterine contraceptive device in pregnancy
O26.841-O26.849Uterine size-date discrepancy complicating pregnancy
O26.851-O26.859Spotting complicating pregnancy
O30.001-O30.93Multiple gestation
O31.00X0-O31.8X99Complications specific to multiple gestation
O32.0XX0-O32.9XX9Maternal care for malpresentation of fetus
O33.0-O33.9Maternal care for disproportion
O34.00-O34.93Maternal care for abnormality of pelvic organs
O35.0XX0-O35.9XX9Maternal care for known or suspected fetal abnormality and damage
O36.0110-O36.0999Maternal care for anti-D [Rh] antibodies
O36.20X0-O36.23X9Maternal care for hydrops fetalis
O36.4XX0-O36.4XX9Maternal care for intrauterine death
O36.5110-O36.5999Maternal care for known or suspected poor fetal growth
O36.60X0-O36.63X9Maternal care for excessive fetal growth
O36.70X0-O36.73X9Maternal care for viable fetus in abdominal pregnancy
O36.80X0-O36.80X9Pregnancy with inconclusive fetal viability
O36.8120-O36.8199Decreased fetal movements
O36.8910-O36.8999Maternal care for other specified fetal problems
O36.90X0-O36.93X9Maternal care for fetal problem, unspecified
O40.1XX0-O40.9XX9Polyhydramnios
O41.0XX0-O41.93X9Other disorders of amniotic fluid and membranes
O42.00-O42.92Premature rupture of membranes
O43.021-O43.029Fetus-to-fetus placental transfusion syndrome
O43.101-O43.199Malformation of placenta
O43.211-O43.93Morbidly adherent placenta, other/unspecified placental disorder
O44.00-O44.13Placenta previa
O45.001-O45.93Premature separation of placenta (abruptio placentae)
O46.001-O46.93Antepartum hemorrhage
O47.00-O47.9False labor
O48.0-O48.1Late pregnancy
O60.00-O60.03Preterm labor without delivery
O73.0-O73.1Retained placenta and membranes, without hemorrhage
O76Abnormality in fetal heart rate and rhythm complicating labor and delivery
Z34.00-Z34.93Encounter for supervision of normal pregnancy [codes 76801, 76805, when criteria are met]
  
Discussion/General Information

The American College of Obstetricians and Gynecologists (ACOG) 2009 Practice Bulletin for Ultrasonography in Pregnancy lists the following recommendations:

The following conclusions are based on good and consistent evidence (Level A):

The following conclusions are based on limited or inconsistent evidence (Level B):

The following conclusion and recommendation are based primarily on consensus and expert opinion (Level C):

Definitions

Ultrasound: A screening or diagnostic technique in which very high frequency sound waves are passed into the body, and the reflected echoes are detected and analyzed to build a picture of the internal organs or of a single fetus or multiple fetuses in the uterus.

References

Peer Reviewed Publications: 

  1. Poggenpoel EJ, Geerts LT, Theron GB. The value of adding a universal booking scan to an existing protocol of routine mid-gestation ultrasound scan. Int J Gynaecol Obstet. 2012; 116(3):201-205.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American College of Obstetricians and Gynecologists (ACOG). Management of preterm labor. ACOG Practice Bulletin Number 127, June 2012.
  2. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. ACOG Practice Bulletin Number 76, October 2006. Reaffirmed 2011.
  3. American College of Obstetricians and Gynecologists (ACOG). Ultrasonography in pregnancy. ACOG Practice Bulletin Number 101, February 2009. Reaffirmed 2011.
  4. American College of Radiology (ACR). Practice guideline for the performance of obstetrical ultrasound. (2013) Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines. Accessed on December 27, 2013.
  5. Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks gestation). Cochrane Database Syst Rev. 2008; (4):CD001451.
  6. Centers for Medicare and Medicaid Services. National Coverage Determination: Ultrasound diagnostic procedures. NCD #220.5. Effective September 28, 2007. Available at: http://www.cms.hhs.gov/MCD/index_chapter_list.asp?from2=index_chapter_list.asp&list_type=&. Accessed on December 27, 2013.
  7. National Institute for Health and Clinical Excellence. Clinical guideline CG62. Antenatal Care. March 2008. Available at: http://www.nice.org.uk/nicemedia/live/11947/40115/40115.pdf. Accessed on December 27, 2013.
  8. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2010; (4):CD007058.
Index

Maternal Ultrasound
Obstetric

History
StatusDateAction
Revised02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Addition of "cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy" to Medically Necessary Statement. Clarification to Not Medically Necessary Statement. Updated References.
New

02/14/2013

 

MPTAC review. Initial document development.