OB Ultrasound Authorization and Coding Guide
OB Ultrasound Authorization and Coding Guide horizonNJhealth.com 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
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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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.
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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)
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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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OB Ultrasound Authorization and Coding Guide
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
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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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OB Ultrasound Authorization and Coding Guide
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.
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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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OB Ultrasound Authorization and Coding Guide
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.
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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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OB Ultrasound Authorization and Coding Guide
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
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015
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OB Ultrasound Authorization and Coding Guide
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,
