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OB Ultrasound Authorization and Coding Guide
OB Ultrasound
Authorization and
Coding Guide
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Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
Table 1: CPT® Codes for routine ultrasounds
CPT Code
US Description
Covered by GEMS* Authorization
76801
OB US < 14 weeks single fetus
GEMS2
76802
OB US < 14 weeks additional fetus
GEMS2
76813
OB US nuchal measurement 1 gestation
GEMS2
76814
OB US nuchal measurement add-on
GEMS2
76805
OB US ≥ 14 weeks single fetus
GEMS3
76810
OB US ≥ 14 weeks addl fetus
GEMS3
76817
Transvaginal US Obstetrical
GEMS2 (only 1 use in 1st Trimester
[ < 14 weeks])
* GEMS stands for “Getting Early Maternity Services”
Table 2: Prior Authorization Requirement for Frequently Used Ultrasounds
CPT Code
US Description
Pre-Authorization Required
76811
OB US detailed single fetus
Yes
76812
OB US detailed additional fetus
Yes
76815
OB US limited fetus(s)
Yes
76816
OB US follow-up per fetus
Yes
76817
Transvaginal US Obstetrical
Yes if prior TVS was performed or
greater than 14 weeks gestation
76818
Fetal bpp with non-stress testing
Yes
76819
Fetal bpp without non-stress testing
Yes
76820
Doppler velocimetry, fetal; umbilical artery
Yes
76821
Doppler velocimetry, fetal; middle cerebral
artery
Yes
76825
Echocardiography, fetal, cardiovascular
system, initial
Yes
76826
Echocardiography, fetal, cardiovascular
system, follow up
Yes
76827
Doppler echocardiography, initial
Yes
76828
Doppler echocardiography, follow up
Yes
93325
Doppler echocardiography color flow
velocity
Yes
Amniocentesis-OB U/S Guided
Yes
59000-76946
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OB Ultrasound Authorization and Coding Guide
A. Indications for a Detailed, Limited and
Follow-up Ultrasound
Limited, follow-up transabdominal and transvaginal obstetric
ultrasounds will be approved for fetal, obstetrical or maternal
complications.
B. Indications for Biophysical Profile
A biophysical profile is indicated when an appropriate,
approved medical condition is present.
C. Indications for a Vessel Doppler
Specialty vessel doppler ultrasounds are indicated when
an appropriate, approved medical condition is present.
Vessel doppler exams are expected to be used infrequently
for selected clinical scenarios and performed by clinicians with
specialized expertise in the performance and interpretation
of the study (refer to Table 3.)
D. Indications for Fetal Echo
According to the 2010 AIUM’s practice guideline on
Performance of Fetal Echocardiography, “indications for
fetal echocardiography are often based on a variety of
parental and fetal risk factors for congenital heart disease.
However, most cases are not associated with known risk factors.”
Common indications for a detailed scan of the fetal heart include,
but are not limited to, the conditions listed in Table 3.
If any of these are present, the patient should be referred for
fetal echocardiography at 18 to 24 weeks of gestation.
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Table 3: Diagnostic Codes related to Maternal/Fetal Conditions (not all-inclusive)
** Indicates multiple code variations for the diagnosis
Absence or hypoplasia of umbilical artery
ICD 10
Indications
Q27.0
Advanced maternal age
ICD 10
O09.519 - O09.523
Indications
Maternal age of 35 years or older for a screening ultrasound from
12 through 27 weeks of gestation.
Amniotic fluid volume abnormalities
ICD 10
Indications
Oligohydramnios
Decreased amniotic fluid volume relative to gestational age, characterized
by an amniotic fluid index (AFI) less than 5 cm or single deepest pocket less
than 2 cm.
O41.**
Polyhydramnios
O40 – O40.9
Increased amniotic fluid volume relative to gestational age characterized by
an AFI greater than or equal to 24 cm.
Antiphospholipid Syndrome
ICD 10
Indications
Antiphospholipid syndrome (APS) or other maternal autoimmune disease
D68.51 - D68.62,
M32.10 (Systemic Lupus
Erythematosus),
L93.0 (Discoid Lupus
Erythematosus),
L93.2 (Other Local Eupus
Erythematosus)
Documented previous diagnosis of antiphospholipid syndrome (APS), or
other maternal autoimmune disease, such as Systemic Lupus Erythematosis
(SLE).
Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)
D89.89
Documented previous diagnosis of autoimmune antibodies –
anti-Ro (SSA)/anti-La (SSB)
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Asthma
ICD 10
Indications
Severe, documented asthma requiring daily medication such as long-acting
beta-agonist and/or inhaled or oral steroids.
J45.**
Blood Incompatibility
ICD 10
Indications
Rhesus isoimmunization affecting management of mother, antepartum condition or complication
O36.01**, O36.09**
Isoimmunization from other and unspecified blood-group incompatibility affecting management of
mother, antepartum condition or complication
O36.11**, O36.19**
Cardiac
ICD 10
Indications
Cardiac Disease, Maternal
I51.9
Documented diagnosis affecting maternal-fetal condition during pregnancy
Mitral valve disorder, aortic valve disorders, tricuspid valve disorders, specified as nonrheumatic, and
pulmonary valve disorders
I05.9, I36.9, I37.0
Documented diagnosis affecting maternal-fetal condition during pregnancy
Endomyocardial fibrosis
I42.3
Documented diagnosis affecting maternal-fetal condition during pregnancy
Endocardial fibroelastosis
I42.4
Documented diagnosis affecting maternal-fetal condition during pregnancy
Alcoholic cardiomyopathy
I42.6
Documented diagnosis affecting maternal-fetal condition during pregnancy
Cardiomegaly
I51.7
Documented diagnosis affecting maternal-fetal condition during pregnancy
Congenital cardiovascular disorders
Q24.9
Documented diagnosis affecting maternal-fetal condition during pregnancy
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Cardiac (continued)
ICD 10
Indications
Other cardiovascular diseases
I51.9
Documented diagnosis affecting maternal-fetal condition during pregnancy
Personal history of surgery to heart and great vessels
Z98.89
Personal history of surgery to heart and great vessels
Abnormality in fetal heart rate or rhythm, antepartum condition or complication [suspected or
documented fetal arrhythmia]
O76
Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm before the onset of labor, affecting fetus or newborn
P03.810
Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm, unspecified as to time of onset, affecting fetus or newborn
P03.819
Documented fetal arrhythmia during current pregnancy
Abnormal finding on antenatal screening
28.9
Abnormal finding on antenatal screening
Family history of other cardiovascular diseases
Z82.49
First degree relative with history of congenital heart disease
Bulbus cordis anomalies and anomalies of cardiac septal closure, other congenital anomalies of heart,
other congenital anomalies of circulatory system, and anomalies of great veins
Q20.8, Q21.8
Documented diagnosis affecting maternal-fetal condition during pregnancy
Nonspecific abnormal findings on radiological and other exam of other intrathoracic organs [abnormal
or incomplete cardiac evaluation on an anatomic scan, four-chamber study]
R93.1, R93.8
Documented diagnosis affecting maternal-fetal condition during pregnancy
Extracardiac anomaly
Q89.9
Documented diagnosis affecting maternal-fetal condition during pregnancy
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Cervical Length Screening
ICD 10
O26.879
Indications
Documented physician concern about risk of premature delivery in support of
a screen for cervical length shortening in low-risk, asymptomatic patient.
Cholestasis of pregnancy
ICD 10
O26.619
Indications
Documented elevated serum bile acid (upper limit of normal is between
10 and 14 μmol/L). or physician diagnosis based on patient symptoms.
Chromosomal Abnormalities and CHD
ICD 10
Indications
Down’s syndrome
Q90
Ehlers-Danlos syndrome
Q79.6
Edward’s syndrome
Q91.2
Trisomy 13
Q91.7
Trisomy 18
Q91.3
Turner’s syndrome
Q96.*
Cri du chat syndrome
Q93.4
Wolf-Hirshhorn syndrome
Q93.3
DiGeorge syndrome (deletion 22q11)
D82.1
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Decreased Fetal Movement
ICD 10
O36.81**
Indications
Documented maternal perception of decreased fetal activity.
Diabetes Mellitus
ICD 10
Indications
Diabetes Mellitus - Gestational
O24.**
Controlled by diet, without requiring medications.
Diabetes mellitus-Type I or Type II, pre-gestational
E08-E13.**
Controlled by diet, without requiring medications.
Diabetes mellitus complicating pregnancy
O24.91*
Controlled by diet, without requiring medications.
Syndrome of “infant of a diabetic mother”, fetus or newborn
P70.*
Controlled by diet, without requiring medications.
Long-term (current) use of insulin
Diabetes diagnosed prior to pregnancy requiring medication (e.g. insulin,
glyburide) to control.
Z79.4
Drug/ETOH abuse, or methadone use/abuse
ICD 10
F10-F16.**, F18-F19.**
Indications
Active, documented in chart.
Epilepsy
ICD 10
Indications
Epilepsy and recurrent seizures
G40.**
Documented diagnosis affecting maternal-fetal condition during pregnancy
Epilepsy complicating pregnancy
G40.909
Documented diagnosis affecting maternal-fetal condition during pregnancy
Convulsions
R.56.9
Documented diagnosis affecting maternal-fetal condition during pregnancy
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Epilepsy (continued)
ICD 10
Indications
Post traumatic seizures
R56.1
Documented diagnosis affecting maternal-fetal condition during pregnancy
Adverse effects of other and unspecified anticonvulsants
T42.****
Documented diagnosis affecting maternal-fetal condition during pregnancy
Fetal Abnormality
ICD 10
Indications
Fetal anomaly, major
F10-F16.**, F18-F19.**
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Multiple congenital anomalies
Q89.7
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Family history of congenital anomalies
Z82.79
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Central nervous system malformation in fetus affecting management of mother, antepartum condition or
complication
O35.0XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Known or suspected chromosomal abnormality in fetus affecting management of mother, antepartum condition
or complication
O35.1XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Hereditary disease in family possibly affecting fetus affecting management of mother, antepartum condition or
complication
O35.2XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Suspected damage to fetus from viral disease in mother, antepartum condition or complication
O35.3XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
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Fetal Abnormality (continued)
ICD 10
Indications
Suspected damage to fetus from other disease affecting management of mother, antepartum condition or
complication
O35.4XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Suspected damage to fetus from drugs affecting management of mother, antepartum condition or
complication
O35.5XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Other known or suspected fetal abnormality, not elsewhere classified, antepartum condition or
complication
O35.8XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Unspecified known or suspected fetal abnormality, not elsewhere classified, affecting management of
mother, antepartum condition or complication
O35.9XX0
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
Other nonspecific abnormal findings on radiological and other examination of body structure
Suspected or known major structural anomaly, including documented history
of previous congenital anomaly.
R93.8
Poor fetal growth affecting management of mother
Estimated fetal weight less than the 10th percentile for gestational age
Scifres or an estimated fetal weight between the 10th and 15th percentile for
gestational age.
O36.5***
Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication
ICD 10
Indications
Fetal-maternal hemorrhage affecting management of mother, antepartum
condition or complication (ex. vasa previa)
O43.011
Fetal size/due date discrepancy
ICD 10
O26.84
Indications
A significant discrepancy of
3 or more between fundal height (centimeters) to gestational age (weeks).
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Fetus or newborn affected by placental transfusion syndromes
ICD 10
P02.3, O43.0, P50.3
Indications
Fetus or newborn affected by placental transfusion syndromes
Hereditary hemorrhagic telangiectasia
ICD 10
I78.0
Indications
Hereditary hemorrhagic telangiectasia
Hydrocephalic fetus causing disproportion, antepartum condition or complication
ICD 10
O33.6XX0
Indications
Hydrocephalis
Hydrops fetalis not due to isoimmunization, fetus or newborn
ICD 10
P83.2
Indications
Hydrops fetalis not due to isoimmunization, fetus or newborn
Hypertension, chronic
ICD 10
O10.**, I11.**
Indications
Blood pressure ≥ 140 mm Hg systolic and/or 90 mm Hg diastolic, diagnosed
before conception or before twenty (20) weeks gestation.
Hyperthyroid disease, maternal
ICD 10
O99.28*
Indications
Uncontrolled, defined by suppressed TSH level with related maternal symptoms.
Hypothyroid disease, maternal
ICD 10
O99.28*
Indications
Uncontrolled, defined by elevated thyroid stimulating hormone (TSH) and related
maternal symptoms.
Human Immunodeficiency Virus (HIV) infection, maternal
ICD 10
098.7*
Indications
Confirmed HIV, documented in chart.
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Incompetent cervix and no cerclage
ICD 10
034.**, N88.3
Indications
Premature opening of the cervix.
Increased nuchal translucency
ICD 10
Z36
Indications
Increased nuchal translucency
Infection
ICD 10
Indications
Other specified infectious and parasitic diseases of mother, antepartum condition or complication
O98.61*, O98.81*
Other specified infectious and parasitic diseases of mother, antepartum
condition or complication
Unspecified infection or infestation of mother, antepartum condition or complication
Unspecified infection or infestation of mother, antepartum condition or
complication
O98.91*
Unspecified viral infection
B97.89
Unspecified viral infection
Suspected damage to fetus from viral disease in the mother, affecting management of mother, antepartum condition
or complication
O35.3XX0
Suspected damage to fetus from viral disease in the mother, affecting
management of mother, antepartum condition or complication
Intrauterine Fetal Death (IUFD), history
ICD 10
O09.211
Indications
Documented history of IUFD.
Intrauterine Growth Restriction (IUGR)
ICD 10
P05.9
Indications
Estimated fetal weight less than the 10th percentile for gestational age
Scifres or an estimated fetal weight between the 10th and 15th percentile for
gestational age.
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Malpresentation
ICD 10
032.***
Indications
Presentation other than vertex after 36 weeks.
Mental disorders complicating pregnancy, antepartum condition or complication
ICD 10
O99.34*
Indications
Mental disorders complicating pregnancy, antepartum condition or complication
MSAFP (Maternal serum alpha-fetoprotein) level, elevated
ICD 10
Indications
Unexplained, elevated MSAFP, > 2.5 MoMs (quantitative unit of measure for
MSAFP reported as multiples of the median).
Z36
Multiple gestations
ICD 10
O30-O31.**
Indications
Two or more fetuses.
Monochorionic twins
O30.1
Twins that share a placenta and an outer membrane.
Twin gestation, monochorionic/diamnionic
O30.039
Twins that share a placenta and outer membrane
Noxious Influences
ICD 10
Indications
Noxious influences affecting fetus or newborn via placenta or breast milk, alcohol
P04.3, Q86.0
Active, documented in chart.
Noxious influences affecting fetus or newborn via placenta or breast milk, anticonvulsants
P04.1
Documented medication use, affecting maternal-fetal condition during pregnancy
Antimetabolic agents affecting fetus or newborn via placenta or breast milk
P04.1
Documented medication use, affecting maternal-fetal condition during pregnancy
Noxious influences affecting fetus via placenta or breast milk, other
P04.8
Noxious influences affecting fetus via placenta or breast milk, other
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Obesity in pregnancy
ICD 10
O99.21*
Indications
Maternal body mass index (BMI) > 30 kg/m2 conception (usually determined
during first obstetrical exam).
Other specified antenatal screening [when reported alone - indicates routine screen without
signs or symptom
ICD 10
Z36
Indications
Other specified antenatal screening
Other specified complications of pregnancy, antepartum condition or complication
ICD 10
O26.1**, O26.4**,
O26.8**
Indications
Other specified complications of pregnancy, antepartum condition or complication
PAPP-A (Pregnancy-associated plasma protein A), abnormal value
ICD 10
O35.**
Indications
Unexplained, <0.3 MoMs (multiples of the median).
Phenylketonuria
ICD 10
E70.1
Indications
Phenylketonuria
Placenta previa
ICD 10
Indications
Asymptomatic (without bleeding) with documented prior ultrasound report of
placenta located near or over the internal cervical orifice.
O44.**
Placental abruption
ICD 10
O45.**
Indications
Vaginal bleeding with suspected placental abruption.
Post term pregnancy
ICD 10
O48.**
Indications
Pregnancy that is at or beyond forty (40) weeks of gestation
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Pre-eclampsia
ICD 10
O10.*** and
additional codes
Indications
New onset of blood pressure elevation exceeding 140/90 mm Hg after
twenty (20) weeks gestation.
Pregnancy resulting from assisted reproductive technology
ICD 10
O09.819
Indications
Pregnancy resulting from assisted reproductive technology
Premature rupture of membranes
ICD 10
O42.0**
Indications
Confirmed and documented in chart.
Pre-term delivery history
ICD 10
Indications
Patient has had a previous pregnancy that delivered between 20 and 37 weeks of
gestation.
Z87.51
Pre-term delivery risk screening of low-risk patient (cervical shortening)
ICD 10
Indications
Documented concern that supports need for transvaginal ultrasound to screen for
cervical length shortening.
N88.3
Pre-term labor
ICD 10
O60.1***
Indications
Active labor defined as regular painful contractions (≥4 in 20 minutes or ≥8 in one
hour) and documented cervical change.
Rare Genetic Diseases
ICD 10
Indications
Situs inversus
Q89.3
Situs inversus
Marfan syndrome
Q87.40
Marfan syndrome
Smith-Lemli-Opitz syndrome
E78.72
Smith-Lemli-Opitz syndrome
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Rare Genetic Diseases (continued)
ICD 10
Indications
Ellis-van Creveld
Q77.6
Ellis-van Creveld
Holt-Oram syndrome
Q23.8, Q24.8
Holt-Oram syndrome
Noonan syndrome
Q87.1
Noonan syndrome
Mucopolysaccharidoses
E76.**
Mucopolysaccharidoses
Goldenhar syndrome (hemifacial microsomia)
Q75.9
Goldenhar syndrome (hemifacial microsomia)
Other Congenital Anomalies (VACTERL association [tracheal and esophageal malformations associated
with vertebral, anorectal, cardiac, renal, radial, and limb abnormalities], William’s syndrome)
E78.71, Q87.**,
Q89.8
Other Congenital Anomalies (VACTERL association [tracheal and esophageal
malformations associated with vertebral, anorectal, cardiac, renal, radial, and limb
abnormalities], William’s syndrome)
Renal disease, maternal
ICD 10
O26.839
Indications
Documented history of parenchymal renal disease prior to pregnancy.
Rheumatoid arthritis
ICD 10
M06.9
Indications
Rheumatoid arthritis
Rubella exposure
ICD 10
B06.9
Indications
Rubella exposure
Screening for malformation using ultrasonics [when reported alone - indicates routine screen without signs
or symptoms]
ICD 10
Z36
Indications
Screening for malformation using ultrasonics [when reported alone indicates routine screen without signs or symptoms]
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Sicca syndrome (Sjörgen’s syndrome)
ICD 10
M35
Indications
Sicca syndrome
Sickle cell disease, maternal
ICD 10
D57.1
Indications
Documented maternal sickle cell disease (not just trait)
Systemic sclerosis
ICD 10
M34
Indications
Systemic sclerosis
Teratogen (eg. Retinoid) exposure
ICD 10
Z20
Indications
Teratogen (eg. Retinoid) exposure
Unspecified diffuse connective tissue disease
ICD 10
L94.9
Indications
Unspecified diffuse connective tissue disease
Vaginal bleeding
ICD 10
N93.9, O20.0
Indications
Suspected placental abruption, suspected placenta previa, suspected
spontaneous abortion, etc.
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Situations beyond the medical conditions above:
Please note that indications adjunct to procedures (an ultrasound may be indicated for
amniocentesis, amnioinfusion, cervical cerclage, fetoscopy, shunt placement, etc) and other high-risk
medical conditions not listed above will be allowed antenatal testing upon request.
Three-dimensional (3D) and four-dimensional (4D) Ultrasounds are considered experimental and
investigational as there is no evidence that they alter management over a two-dimensional (2D)
ultrasound in a way that improves outcomes.
Common codes not covered for Fetal Echo (not all-inclusive).
ICD 10
Description
099.810 - 099.815
Abnormal glucose tolerance complicating pregnancy
009.511 - 009.519
Elderly primigravida [screening]
009.521 - 009.529
Elderly multigravida [screening]
Z13.228
Special screening for endocrine, nutritional, metabolic and
immunity disorders [screening for cystic fibrosis]
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References
American College of Radiology. (2014). ACR Appropriateness Criteria® Retrieved from https://acsearch.acr.org/list
American Institute of Ultrasound in Medicine. (2010). AIUM practice guideline for the performance of
obstetric ultrasound examinations. J Ultrasound Med, 9(1), 157-166.
Retrieved from http://www.jultrasoundmed.org/content/29/1/157.full.pdf+html
American Institute for Ultrasound in Medicine (AIUM). AIUM practice guideline for the performance of fetal
echocardiography. Laurel, MD: AIUM; 2010. Available at: https://www.smfm.org/attachedfiles/fetalEchoaiumsmfm.pdf
Accessed July 29, 2015
Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA Guidelines for the clinical application of echocardiography:
Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice
guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American
Society of Echocardiography. J Am Coll Cardiol. 1997;29(4):862-879.
Davies, G.A.L., Maxwell, C., McLeod, L., Gagnon, R., Basso, M., Bos, H., … Society of Obstetricians and Gynaecologists
of Canada. (2010). SOGC clinical practice guideline: Obesity in pregnancy.
J Obstet Gynaecol Can, 32, 165. Retrieved from http://www.ncbi.nlm.nih.gov
Desilets V, Audibert F; Society of Obstetrician and Gynaecologists of Canada. Investigation and management of
non-immune fetal hydrops. J Obstet Gynaecol Can. 2013; 35(10):923-938.
Freeman, R.K. (2008). Antepartum testing in patients with hypertensive disorders in pregnancy.
Semin Perinatol, 32(4), 271-273. doi: 10.1053/j.semperi.2008.04.009.
Wilson KL, Czerwinski JL, Hoskovec JM, et al. NSGC practice guideline: Prenatal screening and diagnostic testing
options for chromosome aneuploidy. J Genet Couns. 2013; 22(1):4-15.
Source: CPT copyright 2014 American Medical Association. All rights reserved.
CPT is a registered trademark of the American Medical Association.
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