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Date Printed: October 20, 2017: 11:49 AM

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04-76500-01

Original Effective Date: 06/15/02

Reviewed: 04/24/14

Revised: 05/15/14

Subject: Ultrasound in Maternity Care

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates

 

 
           

DESCRIPTION:

Note: This guideline addresses obstetrical ultrasound examinations during the first, second and third trimester of pregnancy.

This guideline is based on the American College of Obstetricians and Gynecologists (ACOG) Ultrasonography in Pregnancy Practice Bulletin (2009, Reaffirmed 2011).

Obstetrical ultrasound, also called obstetric sonogram or sonographic examination is an imaging test that uses high frequency sound waves to see how a fetus or baby is developing in the uterus and assess female pelvic organs. An obstetrical ultrasound may be performed during each trimester (first, second and third), using a transabdominal or transvaginal approach or both. The American College of Obstetricians and Gynecologists (ACOG) uses the following terms to describe various types of ultrasound examinations performed during the second or third trimesters:

Standard obstetric ultrasound examination: Includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, fetal number and anatomic survey. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible.

Limited obstetric ultrasound examination: Does not replace a standard obstetric ultrasound examination; performed when a specific question requires investigation. For example, to confirm fetal heart activity in a patient experiencing vaginal bleeding or to establish fetal presentation in a laboring patient. A limited obstetric ultrasound examination may also be performed in any trimester to evaluate interval growth, estimate amniotic fluid volume, evaluate the cervix, and assess the presence of cardiac activity.

Specialized obstetric ultrasound examination: A detailed or targeted anatomic examination is performed when an anomaly is suspected on the basis of history, laboratory abnormalities (e.g., pregnancy-associated plasma protein A (PAPP-A), human chorionic gonadotropin (hcG), inhibin A, chorionic villus sampling (CVS)), or the results of either a limited or standard obstetric ultrasound examination.

First Trimester Obstetric Ultrasound Examination

A first-trimester obstetric ultrasound examination is an ultrasound examination performed before 13 weeks and 6 days of gestation. Indications for performing first-trimester obstetric ultrasound examinations include, but are not limited to the following indications:

• To confirm the presence of an intrauterine pregnancy

• To evaluate a suspected ectopic pregnancy

• To define the cause of vaginal bleeding

• To evaluate pelvic pain

• To estimate gestational age

• To diagnose or evaluate multiple gestations

• To confirm cardiac activity

• As an adjunct to chorionic villus sampling, embryo transfer, and localization and removal of an intrauterine device

• To assess for certain fetal anomalies, such as anencephaly, in patients at high-risk

• To evaluate maternal pelvic masses or uterine abnormalities

• To screen for fetal aneuploidy

• To evaluate a suspected hydatidiform mole

Second and Third Trimester Obstetric Ultrasound Examination

A second and third trimester obstetric ultrasound examination can be of benefit in many situations. Indications for performing second and third-trimester obstetric ultrasound examinations include, but are not limited to the following indications:

• Estimation of gestational age

• Evaluation of fetal growth

• Evaluation of vaginal bleeding

• Evaluation of abdominal and pelvic pain

• Evaluation of cervical insufficiency

• Determination of fetal presentation

• Evaluation of suspected multiple gestation

• Adjunct to aminocentesis or other procedure

• Significant discrepancy between uterine size and clinical dates

• Evaluation of pelvic mass

• Evaluation of suspected hydatidiform mole

• Adjunct to cervical cerclage placement

• Evaluation of suspected ectopic pregnancy

• Evaluation of suspected fetal death

• Evaluation of suspected uterine abnormality

• Evaluation of fetal well-being

• Evaluation of suspected amniotic fluid abnormalities

• Evaluation of suspected placental abruption

• Adjunct to external cephalic version

• Evaluation for premature rupture of membranes and/or premature labor

• Evaluation for abnormal biochemical markers

• Follow-up evaluation of a fetal anomaly

• Follow-up evaluation of placental location for suspected placental previa

• Evaluation for history of previous congenital anomaly

• Evaluation of fetal condition in late registrants for prenatal care

• To assess for findings that may increase the risk for aneuploidy

• Screening for fetal anomalies

According to ACOG, in the absence of specific indications for obstetric ultrasound examination; obstetric ultrasound examination between 18-20 weeks of gestation allows for a reasonable survey of fetal anatomy and an accurate estimation of gestational age. At 18-20 weeks of gestation, anatomically complex organs, such as the fetal heart and brain can be imaged with sufficient clarity to allow detection of many major malformations. This recommendation is based primarily on consensus and expert opinion. Also, ACOG notes that it may be possible to document normal structures before 18 weeks, although some structures can be difficult to visualize because of fetal size, position and movement, maternal abdominal scars and increased maternal abdominal wall thickness. A second or third-trimester obstetric ultrasound examination may pose technical limitations for an anatomic evaluation because of suboptimal imaging, when this occurs, the report of the obstetric ultrasound examination should document the nature of the technical limitation. A follow-up examination may be helpful.

Three-dimensional (3D) ultrasound (US) is used to create both a surface image of the fetus in utero and cross-sectional images from any angle. In constructing the 3D US image, the software automatically records and stores the image as part of the process. The stored 3D US image can be rotated for different surface views and cross sections from angles not available with two-dimensional (2D) US.

The Food and Drug Administration (FDA), views the use of US equipment, such as 3D and 4D US devices, for making “keepsake” fetal videos as an unapproved use of the medical device.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Ultrasound in Maternity Care to expedite the medical review process.

1. Click the link Ultrasound in Maternity Care - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: Coverage for obstetrics (OB) ultrasounds is subject to the member’s benefit terms, limitations and maximums. Refer to contract language regarding obstetrics (OB) ultrasounds.

An initial obstetrical ultrasound examination meets the definition of medical necessity.

Obstetrical ultrasound examination in the first trimester of pregnancy meets the definition of medical necessity, for a medical reason including, but is not limited to the following:

• Evaluation of suspected ectopic pregnancy

• Evaluation of vaginal bleeding

• Evaluation of pelvic pain

• Estimation of gestational age

• Diagnosis or evaluation of multiple gestations

• To confirm cardiac activity

• Assessment of fetal anomalies in high-risk individuals

• Evaluation of maternal pelvic masses and/or uterine abnormalities

• Evaluation of suspected hydatidiform mole

Obstetrical ultrasound examination in the second and third trimester of pregnancy meets the definition of medical necessity, for a medical reason including, but is not limited to the following:

• Estimation of gestational age

• Evaluation of fetal growth

• Evaluation of vaginal bleeding

• Evaluation of abdominal and pelvic pain

• Evaluation of cervical insufficiency

• Determination of fetal presentation

• Evaluation of multiple gestation (e.g., growth discrepancy)

• Evaluation of pelvic mass

• Evaluation of suspected hydatidiform mole

• Evaluation of suspected ectopic pregnancy

• Evaluation of suspected fetal death

• Evaluation of suspected uterine abnormality

• Evaluation of suspected amniotic fluid abnormalities

• Evaluation of suspected placental abruption

• Evaluation for premature rupture of membranes and/or premature labor

• Follow-up evaluation of a fetal anomaly

• Follow-up evaluation of placental location for suspected placental previa

The use of two-dimensional (2D), three-dimensional (3D), or four-dimensional (4D) ultrasound (e.g., keepsake ultrasound, keepsake portraits) to only view the fetus, obtain a picture of the fetus or determine the fetal gender without a medical indication does not meet the definition of medical necessity. The FDA views the use of US equipment, such as 3D and 4D devices for making “keepsake” fetal videos as an unapproved use of the medical device. There is a lack of scientific evidence in the peer-reviewed medical literature regarding the impact of the use of (2D), three-dimensional (3D), or four-dimensional (4D) ultrasound without a medical indication on health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe obstetrical ultrasound of the pregnant uterus:

CPT Coding:

76801

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (less than 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 (less than 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure performed)

76805

Ultrasound, pregnant uterus, real time with image documentation; (fetal and maternal evaluation), after first trimester (greater than or equal to 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 (greater than or equal to 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation

76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position AND/OR qualitative amniotic fluid volume), one or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., 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

REIMBURSEMENT INFORMATION:

Refer to section entitled Position Statement.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for ultrasound of the pregnant uterus

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Abruptio placenta: Premature separation of the placenta from the wall of the uterus.

Anenecephaly: a defect in the closure of the neural tube during fetal development. The neural tube is a narrow channel that folds and closes between the 3rd and 4th weeks of pregnancy to form the brain and spinal cord of the embryo. Anencephaly occurs when the cephalic or head end of the neural tube fails to close, resulting in the absence of a major portion of the brain, skull, and scalp.

Aneuploidy: having or being a chromosome number that is not an exact multiple of the usually haploid number.

Antepartum: occurring before the onset of labor.

Chorionic villus sampling (CVS): removal of a small piece of placenta tissue (chorionic villi) from the uterus during early pregnancy (about 10 to 12 weeks) for prenatal diagnosis of genetic defects.

Ectopic pregnancy: gestation elsewhere than in the uterus (as in a fallopian tube or in the peritoneal cavity).

Hydatidiform mole: a mass in the uterus that consists of enlarged edematous degenerated chorionic villi growing in clusters resembling grapes, that typically develops following fertilization of an enucleate egg, and that may or may not contain fetal tissue.

Macrosomia: significant overgrowth.

Missed abortion: intrauterine death of a fetus that is not followed the exit of the product of conception from the body.

Oligohydramnios: deficiency of amniotic fluid sometimes resulting in an embryonic defect through adherence between embryo and amnion.

Placenta previa: an abnormal implantation of the placenta at or near the internal opening of the uterine cervix so that it tends to precede the child at birth usually causing severe maternal hemorrhage.

Trimester: any of the three month periods into which pregnancy is divided.

• First trimester of pregnancy: less than 14 weeks

• Second trimester of pregnancy: weeks 14- 28

• Third trimester of pregnancy: weeks 28- 40

RELATED GUIDELINES:

Infertility, 02-6000-24
Measurement of Fetal Nuchal Translucency for Detection of Down Syndrome, 03-59000-17

OTHER:

Other names used to report ultrasound in maternity care:

Obstetrical ultrasound

Obstetrical ultrasonography

Sonography

REFERENCES:

  1. American College of Obstetricians and Gynecologists (ACOG) Committee Opinion-Nonmedical Use of Obstetric Ultrasonography, Number 297, August 2004.
  2. American College of Obstetricians and Gynecologists (ACOG) Committee Opinion-Guidelines for Diagnostic Imaging During Pregnancy, Number 299, September 2004.
  3. American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin-Ultrasonography in Pregnancy, Number 58, December 2004.
  4. American College of Radiology (ACR) Guideline for the Performance of Antepartum Obstetrical Ultrasound, 10/01/03.
  5. American College of Radiology (ACR) Guideline for the Performance of Obstetrical Ultrasound, 2007.
  6. American Institute of Ultrasound Medicine Official Statement for 3D Technology, 11/12/05.
  7. American Institute of Ultrasound Medicine Official Statement for Keep Sake Fetal Imaging, 06/22/05.
  8. American Institute of Ultrasound Medicine (AIUM) Practice Guideline for the Performance of Obstetric Ultrasound Examinations, 2007.
  9. Institute for Clinical Systems Improvement (ICSI) Health Care Guideline: Routine Prenatal Care Fourteenth Edition, July 2010.
  10. Maxwell C, Glanc P. Imaging and obesity: a perspective during pregnancy. American Journal of Roentgenology 2001; 196(2):311-319.
  11. Moran M, McAuliffe FM. Imaging and assessment of placental function. Journal of Clinical Ultrasound 2011; 39(7): 390-398.
  12. Nonmedical use of obstetric ultrasonography. ACOG Committee Opinion No. 297. American College of Obstetricians and Gyncologists 2004 (Reaffirmed 2009); 104: 423-4.
  13. Ultrasonography in pregnancy. ACOG Practice Bulletin No. 101. American College of Obstetricians and Gynecologists 2009 (reaffirmed 2011); 113: 451-61.
  14. U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH)-Fetal Keepsake Videos, 08/30/05.
  15. Whitworth M, Bricker L, Neilson JP et al. Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews 2010; 4 (16): CD007058.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/24/14.

GUIDELINE UPDATE INFORMATION:

06/15/02

Medical Coverage Guideline Reformatted; revised diagnosis list and limitations.

11/15/02

Revised to include additional ICD-9 diagnosis codes.

01/01/03

2003 CPT code update.

06/15/04

Scheduled review, no revisions.

04/15/06

Revised description section to include indications for performance of obstetric ultrasound. Added non-covered statement for ultrasounds performed solely without a medical indication. Updated references.

04/15/07

Scheduled review. No change in coverage.

08/15/07

Revision: guideline reformatted.

11/15/07

Updated ICD-9 diagnoses.

05/15/09

Annual review. No change in position statements. Updated references.

02/15/11

Revision; related ICD-10 codes added.

10/01/11

Revision; formatting changes.

12/01/11

Update; added related ICD-10 codes. Revision; changed 656.83 to 656.33. Updated references.

05/15/12

Guideline reviewed. Updated description. Revised position statement; expanded covered indications. Revised and updated ICD-9 and ICD-10 codes. Added cross reference for Infertility MCG, 02-56000-24 and Measurement of Fetal Nuchal Translucency for Detection of Down Syndrome MCG, 03-59000-17. Updated references.

05/15/14

Deleted diagnoses codes and limitation statement for (76801, 76805, 76811, 76815, and 76817).

Date Printed: October 20, 2017: 11:49 AM