Clinical UM Guideline


Subject:  Maternity Ultrasound in the Outpatient Setting
Guideline #:  CG-MED-42Current Effective Date:  04/05/2016
Status:ReviewedLast Review Date:  02/04/2016

Description

This document addresses the use of maternity ultrasound in the outpatient setting. This document does not address nuchal translucency.

Note: 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-10 Diagnosis 
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

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.

The American College of Obstetricians and Gynecologists (ACOG) 2009 (reaffirmed 2015) 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). Antepartum fetal surveillance. ACOG Practice Bulletin Number 154, July 2014.
  2. American College of Obstetricians and Gynecologists (ACOG). Management of preterm labor. ACOG Practice Bulletin Number 127, June 2012. Reaffirmed 2014.
  3. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. ACOG Practice Bulletin Number 76, October 2006. Reaffirmed 2015.
  4. American College of Obstetricians and Gynecologists (ACOG). Ultrasonography in pregnancy. ACOG Practice Bulletin Number 101, February 2009. Reaffirmed 2011. Reaffirmed 2014.
  5. American College of Radiology (ACR). Practice guideline for the performance of obstetrical ultrasound. (2013) (Amended 2014). Available at: http://www.acr.org/Quality-Safety/Standards-Guidelines. Accessed on January 8, 2016.
  6. American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med 2013; 32(6):1083-1101.
  7. Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks gestation). Cochrane Database Syst Rev. 2008; (4):CD001451.
  8. 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 January 8, 2016.
  9. National Institute for Health and Clinical Excellence. Clinical guideline CG62. Antenatal Care. March 2008. Available at: http://www.nice.org.uk/guidance/CG62. Accessed on January 8, 2016.
  10. 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
Reviewed02/04/2016Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.
Reviewed02/05/2015MPTAC review. Updated Coding, Description, Discussion/General Information, and References.
Revised02/13/2014MPTAC review. Addition of "cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy" to Medically Necessary Statement. Clarification to Not Medically Necessary Statement. Updated References.
New02/14/2013MPTAC review. Initial document development.