| Mountain State Medical Policy Bulletin |
| Section: | Radiology |
| Number: | X-17 |
| Topic: | Obstetrical Ultrasound |
| Effective Date: | October 1, 2008 |
| Issued Date: | January 26, 2009 |
| Date Last Reviewed: | 09/2008 |
Indications and Limitations of Coverage
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 for other diagnoses or conditions are considered not medically necessary. Effective January 26, 2009, 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. 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. |
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| 76801 | 76802 | 76805 | 76810 | 76811 | 76812 |
| 76815 | 76816 | 76817 |
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 |
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