Clinical UM Guideline



Subject: Maternity Ultrasound in the Outpatient Setting
Guideline #:  CG-MED-42 Current Effective Date:    10/01/2017
Status: Revised Last Review Date:    02/02/2017

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  
76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; single or first gestation
76802 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks, 0 days), transabdominal approach; each additional gestation
76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; single or first gestation
76810 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> 14 weeks 0 days), transabdominal approach; each additional gestation
76811-76812 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach
76815 Ultrasound, 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
76816 Ultrasound, 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
76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal
   
ICD-10 Diagnosis  
A92.5 Zika virus disease
O00.00-O00.91 Ectopic pregnancy
O01.0-O01.9 Hydatidiform mole
O02.0-O02.9 Other abnormal products of conception
O03.4 Incomplete spontaneous abortion without complication
O03.9 Complete or unspecified spontaneous abortion without complication
O07.4 Failed attempted termination of pregnancy without complication
O09.10-O09.13 Supervision of pregnancy with history of ectopic pregnancy
O09.A0-O09.A3 Supervision of pregnancy with history of molar pregnancy
O09.211-O09.219 Supervision of pregnancy with history of pre-term labor
O09.291-O09.299 Supervision of pregnancy with other poor reproductive or obstetric history
O09.30-O09.33 Supervision of pregnancy with insufficient antenatal care
O09.511-O09.529 Supervision of elderly primigravida and multigravida
O09.891-O09.93 Supervision of other or unspecified high risk pregnancy
O10.011-O10.019 Pre-existing essential hypertension complicating pregnancy
O10.111-O10.119 Pre-existing hypertensive heart disease complicating pregnancy
O10.211-O10.219 Pre-existing hypertensive chronic kidney disease complicating pregnancy
O10.311-O10.319 Pre-existing hypertensive heart and chronic kidney disease complicating pregnancy
O10.411-O10.419 Pre-existing secondary hypertension complicating pregnancy
O10.911-O10.919 Unspecified pre-existing hypertension complicating pregnancy
O11.1-O11.3 Pre-existing hypertension with pre-eclampsia; first, second or third trimester
O11.9 Pre-existing hypertension with pre-eclampsia; unspecified trimester
O14.00-O14.03 Mild to moderate pre-eclampsia; unspecified, second or third trimester
O14.10-O14.13 Severe pre-eclampsia; unspecified, second or third trimester
O14.20-O14.23 HELLP syndrome; unspecified, second or third trimester
O14.90-O14.93 Unspecified pre-eclampsia; unspecified, second or third trimester
O16.1-O16.3 Unspecified maternal hypertension; first, second or third trimester
O16.9 Unspecified maternal hypertension; unspecified trimester
O20.0-O20.9 Hemorrhage in early pregnancy
O21.0-O21.9 Excessive vomiting in pregnancy
O24.011-O24.019 Pre-existing diabetes mellitus, type 1, in pregnancy
O24.111-O24.119 Pre-existing diabetes mellitus, type 2, in pregnancy
O24.311-O24.319 Unspecified pre-existing diabetes mellitus in pregnancy
O24.410-O24.419 Gestational diabetes mellitus in pregnancy
O24.811-O24.819 Other pre-existing diabetes mellitus in pregnancy
O24.911-O24.919 Unspecified diabetes mellitus in pregnancy
O26.20-O26.23 Pregnancy care for patient with recurrent pregnancy loss
O26.30-O26.33 Retained intrauterine contraceptive device in pregnancy
O26.841-O26.849 Uterine size-date discrepancy complicating pregnancy
O26.851-O26.859 Spotting complicating pregnancy
O30.001-O30.93 Multiple gestation
O31.00X0-O31.8X99 Complications specific to multiple gestation
O32.0XX0-O32.9XX9 Maternal care for malpresentation of fetus
O33.0-O33.9 Maternal care for disproportion
O34.00-O34.93 Maternal care for abnormality of pelvic organs
O35.0XX0-O35.9XX9 Maternal care for known or suspected fetal abnormality and damage
O36.0110-O36.0999 Maternal care for anti-D [Rh] antibodies
O36.20X0-O36.23X9 Maternal care for hydrops fetalis
O36.4XX0-O36.4XX9 Maternal care for intrauterine death
O36.5110-O36.5999 Maternal care for known or suspected poor fetal growth
O36.60X0-O36.63X9 Maternal care for excessive fetal growth
O36.70X0-O36.73X9 Maternal care for viable fetus in abdominal pregnancy
O36.80X0-O36.80X9 Pregnancy with inconclusive fetal viability
O36.8120-O36.8199 Decreased fetal movements
O36.8310-O36.8399 Maternal care for abnormalities of the fetal heart rate or rhythm
O36.8910-O36.8999 Maternal care for other specified fetal problems
O36.90X0-O36.93X9 Maternal care for fetal problem, unspecified
O40.1XX0-O40.9XX9 Polyhydramnios
O41.0XX0-O41.93X9 Other disorders of amniotic fluid and membranes
O42.00-O42.92 Premature rupture of membranes
O43.021-O43.029 Fetus-to-fetus placental transfusion syndrome
O43.101-O43.199 Malformation of placenta
O43.211-O43.93 Morbidly adherent placenta, other/unspecified placental disorder
O44.00-O44.53 Placenta previa
O45.001-O45.93 Premature separation of placenta (abruptio placentae)
O46.001-O46.93 Antepartum hemorrhage
O47.00-O47.9 False labor
O48.0-O48.1 Late pregnancy
O60.00-O60.03 Preterm labor without delivery
O73.0-O73.1 Retained placenta and membranes, without hemorrhage
O76 Abnormality in fetal heart rate and rhythm complicating labor and delivery
Z34.00-Z34.93 Encounter 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) 2016 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):

Zika virus was first reported in South America in May 2015 and has since that time has now appeared in the United States. ACOG and the Society for Maternal Fetal Medicine (SMFM) released a practice advisory regarding the current information and recommendations regarding the Zika virus. Recommendations are based on limited data and include:

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) and Society for Maternal Fetal Medicine (SMFM). Practice advisory on Zika virus. Updated December 19, 2016. Available at: http://www.acog.org/About-ACOG/News-Room/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak#evaluation. Accessed on January 3, 2017.
  5. American College of Obstetricians and Gynecologists (ACOG). Ultrasonography in pregnancy. ACOG Practice Bulletin Number 175, December 2016.
  6. American College of Radiology (ACR). ACR-ACOG-AIUM-SRU Practice parameter for the performance of obstetrical ultrasound. (2013). Available at: https://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/US_Obstetrical.pdf . Accessed on February 2, 2017.
  7. American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med 2013; 32(6):1083-1101.
  8. Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks gestation). Cochrane Database Syst Rev. 2008;(4):CD001451.
  9. Centers for Disease Control and Prevention (CDC). Diagnostic Tests for Zika Virus. Updated January 18, 2017. Available at: https://www.cdc.gov/zika/hc-providers/types-of-tests.html . Accessed on February 2, 2017.
  10. 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 February 2, 2017.
  11. Papageorghiou AT, Thilaganathan B, Bilardo CM, et al. ISUOG Interim Guidance on ultrasound for Zika virus infection in pregnancy: information for healthcare professionals. Ultrasound Obstet Gynecol. 2016; 47(4):530-532.
  12. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2010;(4):CD007058.
Websites for Additional Information
  1. American College of Obstetricians and Gynecologists (ACOG). Zika virus updates. Updated January 11, 2017. Available at: http://immunizationforwomen.org/providers/Zika-Virus-Updates. Accessed on February 2, 2017.
  2. Centers for Disease Control and Prevention (CDC). Birth Defects Homepage: Diagnosis. Updated: October 20, 2014. Available at: https://www.cdc.gov/ncbddd/birthdefects/diagnosis.html . Accessed on February 2, 2017.
  3. Centers for Disease Control and Prevention (CDC). Zika Virus. Updated January 9, 2017. Available at: https://www.cdc.gov/zika/prevention/index.html . Accessed on February 2, 2017.
  4. U.S. National Library of Medicine. MedlinePlus. Prenatal ultrasound-series. Review January 5, 2017. Available at: https://medlineplus.gov/ency/presentations/100197_1.htm . Accessed on February 2, 2017.
Index

Maternal Ultrasound
Obstetric

History
Status Date Action
  10/01/2017 Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes.
Revised 02/02/2017 Medical Policy & Technology Assessment Committee (MPTAC) review. Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. Added Websites for Additional Information section. Updated Discussion/General Information, Coding and Reference sections.
  10/01/2016 Updated Coding section with 10/01/2016 ICD-10-CM diagnosis code changes.
Reviewed 02/04/2016 MPTAC review. Updated Discussion/General Information and Reference sections. Removed ICD-9 codes from Coding section.
Reviewed 02/05/2015 MPTAC review. Updated Coding, Description, Discussion/General Information, and References.
Revised 02/13/2014 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.