Clinical UM Guideline


Subject: Maternity Ultrasound in the Outpatient Setting
Guideline #:  CG-MED-42 Publish Date:    09/20/2018
Status: Reviewed Last Review Date:    02/27/2018

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

Q51.20-Q51.28

Other doubling of uterus

Z20.821

Contact with and (suspected) exposure to Zika virus

Z34.00-Z34.93

Encounter for supervision of normal pregnancy [codes 76801, 76805, when criteria are met]

Z36.0-Z36.9

Encounter for antenatal screening of mother

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 Ultrasound 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. In 2016, ACOG and the Society for Maternal Fetal Medicine (SMFM) released a practice advisory regarding the current information and recommendations regarding the Zika virus. The recommendations are based on limited data. In October 2017, ACOG and SMFM released an updated version of the practice advisory based upon updated Centers for Disease Control and Prevention (CDC) recommendations and recently published guidance. Recommendations for the management of a pregnant women with suspected zika virus infection 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. Alldred SK, Takwoingi Y, Guo B, et al. First trimester ultrasound tests alone or in combination with first trimester serum tests for Down's syndrome screening. Cochrane Database Syst Rev. 2017; 3:CD012600.
  2. American College of Obstetricians and Gynecologists (ACOG). Antepartum fetal surveillance. ACOG Practice Bulletin Number 154, July 2014. Reaffirmed 2016.
  3. American College of Obstetricians and Gynecologists (ACOG). Management of preterm labor. ACOG Practice Bulletin Number 171, October 2016.
  4. American College of Obstetricians and Gynecologists (ACOG). Placenta Accreta. Committee Opinion 529, July 2017 (Reaffirmed 2017).
  5. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage. ACOG Practice Bulletin Number 183, October 2017. Reaffirmed 2015.
  6. American College of Obstetricians and Gynecologists (ACOG). Screening for Fetal Aneuploidy. ACOG Practice Bulletin 163, May 2016.
  7. American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal Fetal Medicine (SMFM). Practice Advisory Interim Guidance for Care of Obstetric Patients During a Zika Virus Outbreak. September 15, 2017. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Interim-Guidance-for-Care-of-Obstetric-Patients-During-a-Zika-Virus-Outbreak.  Accessed on February 7, 2018.
  8. American College of Obstetricians and Gynecologists (ACOG). Ultrasound in pregnancy. ACOG Practice Bulletin Number 175, December 2016.
  9. 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 6, 2018.
  10. American Institute of Ultrasound in Medicine. AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med 2013; 32(6):1083-1101.
  11. Bricker L, Neilson JP, Dowswell T. Routine ultrasound in late pregnancy (after 24 weeks gestation). Cochrane Database Syst Rev. 2008;(4):CD001451.
  12. Centers for Disease Control and Prevention (CDC). Diagnostic Tests for Zika Virus. Updated December 12, 2017. Available at: https://www.cdc.gov/zika/hc-providers/types-of-tests.html. Accessed on February 6, 2018.
  13. Centers for Medicare and Medicaid Services. National Coverage Determination: Ultrasound diagnostic procedures. NCD #220.5. Effective September 28, 2007. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_part4.pdf. Accessed on February 6, 2018.
  14. 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.
  15. 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). Routine Tests During Pregnancy. FAQ 133, September 2017. Available at: https://www.acog.org/Patients/FAQs/Routine-Tests-During-Pregnancy. Accessed on February 7, 2018.
  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 7, 2018.
  3. Centers for Disease Control and Prevention (CDC). Zika Virus. Updated January 19, 2018. Available at: https://www.cdc.gov/zika/prevention/index.html. Accessed on February 7, 2018.
  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 7, 2018.
Index

Maternal Ultrasound
Obstetric

History

Status

Date

Action

  09/20/2018 Updated Coding section with 10/01/2018 ICD-10-CM diagnosis code changes; added Q51.20-Q51.28, Z20.821.
  04/25/2018 Updated Coding section to include ICD-10-CM diagnosis codes Z36.0-Z36.9.

Reviewed

02/27/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion/General Information, References and Websites for Additional Information sections.

 

10/01/2017

Updated Coding section with 10/01/2017 ICD-10-CM diagnosis code changes.

Revised

02/02/2017

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.