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. (Note: Refer to Medical Policy Bulletin X-11 for additional information on radiological procedures performed on the same day.)

Code 76817 describes a transvaginal obstetric ultrasound performed separately or in addition to one of the transabdominal examinations described above.

(For transvaginal examinations performed for non-obstetrical purposes, use code 76830.)

First trimester ultrasound studies
Obstetrical ultrasound studies performed in the first trimester (codes 76801, 76802) by either the attending obstetrician or another health care professional (e.g., ultrasonographer, radiologist) are considered medically necessary in the following situations.

• ectopic pregnancy (633.00-633.11, 633.20-633.21, 633.80-633.81, 633.90-633.91)
• molar pregnancy/hydatidiform mole (630-631)
• hemorrhage in early pregnancy (640.01-640.03, 640.81-640.83, 640.91-640.93)
• missed abortion (632)
• hyperemesis gravidarum with metabolic disturbance, antepartum (643.11-643.13)
• habitual aborter (646.31-646.33)
• other antepartum hemorrhage (antepartum or intrapartum, associated with trauma, uterine leiomyoma)(641.81-641.83)
• abnormal findings on previous ultrasound (796.5)
• absence of fetal heart tones (659.73)
• adnexal mass (654.43)
• advanced maternal age (659.53, 659.63)
• carcinoma of cervix uteri (233.1)
• early pregnancy with pain (646.80, 646.83)
• fever (780.6)
• hemoperitoneum (568.81)
• history of greater than 1 loss in 1st trimester (V23.49)
• history of previous cesarean section (654.20, 654.23)
• history of uterine abnormality (654.03, 752.3)
• incompetent cervix (654.50, 654.53)
• leukocytosis (288.8)
• pain, unilateral or generalized (789.00, 789.03, 789.09)
• pregnancy with hypertension (642.93)
• size less than due date (656.53)
• size greater than due date (656.63)
• spotting early in pregnancy (641.93)
• syncope (hypovolemic) (780.2)
• tenderness without rebound (789.67)
• twin pregnancy (651.03)
• triplet pregnancy (651.13)
• quadruplet pregnancy (651.23)
• twin pregnancy with one fetal loss (651.33)
• triplet pregnancy with one or two fetal loss (651.43)
• quadruplet pregnancy with fetal loss and retention of one or more fetus(es)(651.53)
• other multiple pregnancy with fetal loss and retention of one or more fetus(es)(651.63)
• other specified multiple pregnancy (651.83)
• unspecified multiple gestation (651.93)
• tumors of body of uterus (654.13)
• other known or suspected fetal abnormality, not elsewhere classified (655.83)
• benign essential hypertension antepartum (642.03)

NOTE:

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. Participating, preferred, or network providers cannot bill the member for the denied service.

A medically necessary obstetrical ultrasound prior to an abortion is reimbursable. The medical necessity for the service must be documented in the patient's records.

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.

NOTE:

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.

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.

Long-Term Prognosis of Pregnancies Complicated by Slow Embryonic Heart Rates in the Early First Trimester, Journal of Ultrasound Medicine, Vol. 18, August 1999