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| Section: | Radiology |
| Number: | X-17 |
| Topic: | Obstetrical Ultrasound |
| Effective Date: | September 7, 2009 |
| Issued Date: | September 7, 2009 |
| Date Last Reviewed: | 08/2009 |
Indications and Limitations of Coverage
First trimester ultrasound studies
The above criteria for first trimester ultrasound studies also applies to transvaginal obstetrical ultrasound studies (code 76817) when they are performed in the first trimester. Obstetrical ultrasound studies performed in the first trimester for other diagnoses or conditions are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records. The Amercan College of Obstetrics-Gynecology describes the following factors that should typically be evaluated during a first trimester ultrasound study.
Obstetrical ultrasound prior to abortion Description Obstetrical ultrasound is a highly developed technique capable of detecting many fetal structural and functional abnormalities. It is used in detecting ectopic pregnancy and multiple pregnancy, assessing fetal life and function, diagnosing physical anomalies, and guiding physicians in their efforts to treat the fetus. Codes 76801 and 76802 include determination of the number of gestational sacs and fetuses, gestational sac/fetal measurements appropriate for gestation (< 14 weeks 0 days), survey of visible fetal and placental anatomic structure, qualitative assessment of amniotic fluid volume/gestational sac shape and examination of the maternal uterus and adnexa. Codes 76805 and 76810 include determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age (> or = 14 weeks 0 days), survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location and amniotic fluid assessment and, when visible, examination of maternal adnexa. Codes 76811 and 76812 include all elements of codes 76805 and 76810 plus detailed anatomic evaluation of the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy, abdominal organ specific anatomy, number/length/architecture of limbs and detailed evaluation of the umbilical cord and placenta and other fetal anatomy as clinically indicated. The ultrasound report should document the results of the evaluation of each element described above or the reason for non-visualization. Code 76815 represents a focused “quick look” exam limited to the assessment of one or more of the elements listed in code 76815. Code 76816 describes an examination designed to reassess fetal size and interval growth or reevaluate one or more anatomic abnormalities of a fetus previously demonstrated on ultrasound, and should be reported once for each fetus requiring reevaluation using modifier ‘-59’ for each fetus after the first. Code 76817 describes a transvaginal obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above. Code 76830 should be used to report transvaginal examinations performed for non-obstetrical purposes. Refer to Medical Policy Bulletin X-51 for information on the coverage of fetal nuchal translucency thickness measurement performed in the first trimester to detect chromosomal abnormalities and congenital defects (codes 76813, 76814). |
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| 76801 | 76802 | 76805 | 76810 | 76811 | 76812 |
| 76815 | 76816 | 76817 |
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This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. Under FEP, diagnosis code 642.03 is also considered an eligible diagnosis. |
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Long-Term Prognosis of Pregnancies Complicated by Slow Embryonic Heart Rates in the Early First Trimester, Journal of Ultrasound Medicine, Vol. 18, August 1999 American College of Obstetrics-Gynecology Practice Bulletin, Number 101, issued 02/2009. |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
