EXTERNAL USE
Medical Policy
Subject:
Prenatal Ultrasound
Effective Date: March 17, 2010
Important Note
Our medical coverage policies are based on medical necessity consideration, nationally accepted medical
practice standards, review of medical literature and governmental approvals. Benefit determination should be
based in all cases on the applicable contract language. To the extent there are any conflicts between this policy
and the contract language, the contract language will prevail. Exceptions to the policy can be made by health
plan medical directors based on individual circumstances.
Note: Proper application of this policy requires sound nursing and medical judgment. Individual patient
circumstances must be considered when applying this policy.
Purpose
The purpose of the policy is to assist in the development of Policy Administration Module (PAM) edits to
facilitate timely and accurate payment of prenatal ultrasound claims.
Prenatal ultrasound procedure codes not specifically listed in this policy (e.g., fetal nuchal translucency
measurement, fetal echocardiography and biophysical profile) are not included in this policy.
Background
Fetal anatomic examination is not considered medically necessary in the routine screening of a normal
pregnancy.
1. Prenatal ultrasound does not appear to reduce the rate of perinatal morbidity.
2. Significant controversy exists with regard to the sensitivity of routine ultrasonography in detecting fetal
anomalies.
3. More than one detailed fetal anatomic ultrasound examination per pregnancy per practice is considered
experimental and investigational as there is inadequate evidence of the clinical utility of multiple serial detailed
fetal anatomic ultrasounds.
Definitions
Diagnosis Codes and Descriptions – See Appendix A
Policy
All markets except Florida
It is our policy to cover one routine prenatal ultrasound for fetal anatomic survey per member, per pregnancy
(procedural codes 76801 and 76805). Additional prenatal ultrasounds for fetal and maternal evaluation or followup of suspected abnormality (procedural codes 76802, 76810, 76811, 76812, 76815, 76816 and 76817) require a
medical diagnosis and will be paid with the appropriate linked diagnosis code as listed in the table below.
This policy is not applicable to maternal/fetal medicine providers using the following specialty codes:
• S142, S083, S055 and S088
• S164 and S232 (radiologists)
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EXTERNAL USE
•
23 (emergency department Place Of Service [POS])
Procedure code/description
76801 Pregnancy ultrasound (<14 weeks, 0
days), fetal and maternal evaluation
76805 Pregnancy ultrasound (≥14 weeks, 0
days), fetal and maternal evaluation
Rule
Pay only one of
either 76801 or
76805 per ninemonth pregnancy
(279 days).
76811 Pregnancy ultrasound, fetal and
maternal evaluation plus detailed fetal
anatomic examination, transabdominal
approach, single or first gestation
Pay only with
associated diagnosis
codes.
76817 Ultrasound, pregnant uterus,
transvaginal
Pay only with
associated diagnosis
codes.
76802 Pregnancy ultrasound (<14 weeks, 0
days), fetal and maternal evaluation, each
additional gestation
Pay 76802 only with
76801.
76810 Pregnancy ultrasound (≥14 weeks, 0
days), fetal and maternal evaluation, each
additional gestation
Pay 76810 only with
76805.
76812 Pregnancy ultrasound plus detailed
fetal anatomic examination, transabdominal
approach, each additional gestation
Pay 76812 only in
conjunction with
76811.
76815 Pregnancy ultrasound, limited
PEC-ALL-0606-12
Pay these only with
the associated
diagnosis codes for
multifetal gestation.
Pay only with the
associated diagnosis
codes.
2
n/a
Diagnosis code
641.03, 641.13, 641.23, 642.03, 644.03,
646.83, 646.93, 647.63, 648.03, 648.43,
648.83, 648.93, 651.03, 652.23, 654.53,
654.63, 655.03, 655.13, 655.23, 655.43,
655.53, 655.83, 655.90, 655.93, 656.53,
656.63, 656.83, 656.93, 658.03, 658.13,
658.23, 659.53, 659.60, 659.63, 659.73,
(duplicate), V23.7, V23.82, V23.89,
V23.9, V28.4, V28.82
218.9, 620.2, 625.9, 626.0, 626.4,
626.8, 632, 634.91, 634.92, 635.90,
640.00, 640.03, 640.83, 640.93, 641.93,
646.33, 654.53, 654.63, 655.53, 655.83,
659.53, 659.63, 789.04, V23.2, V23.41,
V23.49, V23.89, V23.9, V28.82
651.03, 651.13, 651.23,651.83, 651.93
626.0, 632, 640.03, 640.93, 641.03,
642.03, 642.23, 642.33, 644.03, 651.03,
652.23, 654.53, 655.73, 655.93, 656.53,
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EXTERNAL USE
76816 Ultrasound, pregnant uterus, follow-up
(re-evaluation of fetal size, amniotic fluid
volume, etc.)
Pay only with the
associated diagnosis
codes.
656.63, 656.93, 657.03, 658.03, 658.13,
658.23, 659.73
640.03, 641.03, 641.13, 642.03, 642.23,
642.33, 642,43, 644.03, 646.83, 646.93,
647.63, 648.83, 651.03, 652.23, 654.53,
654.63, 655.03, 655.13, 655.23, 655.53,
655.83, 656.53, 656.63, 656.80, 656.81,
656.83, 659.63, 657.03, 658.03, 658.13,
V23.5, V23.7, V23.82
Policy
Florida market only
It is our policy to cover one routine prenatal ultrasound for fetal anatomic survey per member, per pregnancy
(procedural codes 76801 and 76805). Additional prenatal ultrasounds for fetal and maternal evaluation or followup of suspected abnormality (procedural codes 76802, 76810, 76811, 76812, 76815, 76816 and 76817) require a
medical diagnosis and will be paid with the appropriate linked diagnosis code as listed in the table below.
This policy is not applicable to maternal/fetal medicine providers using the following specialty codes:
• S083
• S164 (radiologist)
• S165 (freestanding radiology facility)
Procedure code/ description
76801 Pregnancy ultrasound
(<14 weeks, 0 days), fetal and
maternal evaluation
76805 Pregnancy ultrasound
(≥14 weeks, 0 days), fetal and
maternal evaluation
76811 Pregnancy ultrasound,
fetal and maternal evaluation
plus detailed fetal anatomic
examination, transabdominal
approach, single or first
gestation
76817 Ultrasound, pregnant
uterus, transvaginal
PEC-ALL-0606-12
Rule
Pay only one of either 76801 or76805
per nine-month pregnancy (279 days).
Diagnosis code(s)
n/a
Cannot bill with Modifier 22.
Pay only providers with specialty types:
Radiology (S164), Maternal/Fetal (S083)
and Freestanding Radiology (S165).
Pay only one per nine-month pregnancy
(279 days).
Limit to three per nine-month
pregnancy (279 days) with associated
diagnoses.
3
n/a
632, 634.91, 640.03, 641.03,
641.13, 654.53, 654.63
June 2012
EXTERNAL USE
76802 Pregnancy ultrasound
(<14 weeks, 0 days), fetal and
maternal evaluation, each
additional gestation
76810 Pregnancy ultrasound
(≥14 weeks, 0 days), fetal and
maternal evaluation, each
additional gestation
Pay 76802 only with 76801.
Pay 76810 only with 76805.
651.03, 651.13, 651.23, 651.83,
651.93
Pay 76812 only with 76811.
Pay only with the associated diagnosis
codes for multifetal gestation.
76812 Pregnancy ultrasound
plus detailed fetal anatomic
examination, transabdominal
approach, each additional
gestation
76815 Pregnancy ultrasound,
limited
76816 Ultrasound, pregnant
uterus, follow-up (re-evaluation
of fetal size, amniotic fluid
volume, etc.)
Pay only three per nine-month
pregnancy (279 days) with the
associated diagnosis codes.
042, 199.0, 199.1, 493.00–493.91,
282.0–282.9, 345.00–345.91,
655.23, 659.53, 659.63, 648.03,
648.83, 648.13, 648.23, 648.53,
648.63, 671.23, 671.33, 671.53,
642.43, 642.53, 642.63, 642.73,
642.03, 642.13, 642.23, 642.33,
655.43, 648.33, 656.23, 656.13,
655.03, 655.13, 655.23, 655.33,
655.43, 655.53, 655.63, 655.73,
655.83, 655.93, 641.23, 658.13,
644.03, 651.03, 651.13, 651.23,
651.83, 651.93, 656.53, 659.43,
647.33, 646.73, 646.23, 647.03,
641.03, 656.63, 653.53, 658.03,
789.01–789.09, 640.03, 632,
656.43, 657.03, 645.13, 645.23,
652.23, 641.93
Exceptions
All markets except Florida:
This policy is not applicable to maternal/fetal medicine providers using the following specialty codes:
• S142, S083, S055 and S088
• S164 and S232 (radiologists)
• 23 (emergency department POS)
Florida market ONLY:
For procedure code 76811, pay only these provider specialty types:
• Radiology (S164)
• Maternal/Fetal Medicine (S083)
• Freestanding Radiology Facility (S165)
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EXTERNAL USE
•
•
•
•
•
Policy History
See Appendix B for updates
March 17, 2010 – Initial review and approval
July 21, 2010 – Review and approval of updates
October 20, 2010 – Review and approval of updates
November 11, 2011 – Review and approval of policy and code updates
June 15, 2012 – Review and approval of code updates
References and Research Materials
1. ACOG Practice Bulletin, Number 101, February 2009 – Ultrasonography in pregnancy.
2. Ewigman, B.G., Crane, J.P., Frigoletto, F.D., LeFevre, M.L., Bain, R.P., McNellis, D. (1993). Effect of prenatal
ultrasound screening on perinatal outcome. RADIUS Study Group. New England Journal of Medicine,
329:821, 7.
3. Grandjean, J., Larroque, D., Levi, S. (1999). The performance of routine ultrasonographic screening of
pregnancies in the Eurofetus Study. American Journal of Obstetrics & Gynecology, 181:446, 54.
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Appendix A
Diagnosis Codes and Descriptions
042
Human immunodeficiency virus [HIV]
199.0
Disseminated malignant neoplasm
199.1
Other malignant neoplasm of unspecified site
218.9
Leiomyoma of uterus, unspecified
282.0
Hereditary spherocytosis
282.1
Hereditary elliptocytosis
282.2
Anemias due to disorders glutathione metabolism
282.3
Other hemolytic anemias due to enzyme deficiency
282.4
Thalassemias
282.41
Sickle-cell thalassemia without crisis
282.42
Sickle-cell thalassemia with crisis
282.49
Other thalassemia
282.5
Sickle-cell trait
282.6
Sickle-cell anemia
282.60
Unspecified sickle-cell anemia
282.61
Hb-S disease without mention of crisis
282.62
Hb-S disease with mention of crisis
282.63
Sickle-cell/Hb-C disease
282.64
Sickle-cell/Hb-C disease with crisis
282.68
Other sickle-cell disease without crisis
282.69
Other sickle-cell anemia
282.7
Other hemoglobinopathies
282.8
Other specified hereditary hemolytic anemias
282.9
Unspecified hereditary hemolytic anemia
345.00
Gen nonconvul epilepsy w/o intract epilepsy
345.01
Gen nonconvul epilepsy w/intractable epilepsy
345.1
Generalized convulsive epilepsy
345.10
Gen convul epilepsy w/o mention intract epilepsy
345.11
Gen convul epilepsy w/intractable epilepsy
345.2
Epileptic petit mal status
345.3
Epileptic grand mal status
345.30
Epileptic grand mal status
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial
seizure
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial
seizure
Localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial
seizure
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial
seizures
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial
seizures
Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial
seizures
345.4
345.40
345.41
345.5
345.50
345.51
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345.6
Infantile spasms
345.60
Infantile spasms without mention intract epilepsy
345.61
Infantile spasms with intractable epilepsy
345.7
Epilepsia partialis continua
345.70
Epilepsia partialis continua w/o intract epilepsy
345.71
Epilepsia partialis continua w/intract epilepsy
345.8
Other forms of epilepsy and recurrent seizures
345.80
Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy
345.81
Other forms of epilepsy and recurrent seizures, with intractable epilepsy
345.9
Unspecified epilepsy
345.90
Unspec epilepsy without mention intract epilepsy
345.91
Unspecified epilepsy with intractable epilepsy
493.00
Extrin asthma w/o stat asthmatcus/ac xacrbat/uns
493.01
Extrinsic asthma with status asthmaticus
493.02
Extrinsic asthma with acute exacerbation
493.1
Intrinsic asthma
493.10
Intrin asthma w/o stat asthmatcus/ac xacrbat/uns
493.11
Intrinsic asthma with status asthmaticus
493.12
Intrinsic asthma with acute exacerbation
493.2
Chronic obstructive asthma
493.20
Chrn obst asthma w/o stat asthmaticus/ac xacrbat
493.21
Chronic obstructive asthma w/status asthmaticus
493.22
Chronic obstructive asthma w/acute exacerbation
493.3
Asthma
493.8
Other forms of asthma
493.81
Exercise-induced bronchospasm
493.82
Cough variant asthma
493.9
Unspecified asthma
493.90
Asthma uns w/o status asthmaticus/ac xacrbat/uns
493.91
Unspecified asthma with status asthmaticus
620.2
Other and unspecified ovarian cyst
625.9
Unspecified symptom associated with female genital organs
626.0
Absence of menstruation
626.8
Other disorders of menstruation and other abnormal bleeding from female genital tract
632
Missed abortion
634.91
Spontaneous abortion incomplete without complication
634.92
Spontaneous abortion complete without complication
635.9
Legally induced abortion unspecified without complication
640.00
Threatened abortion unspecified as to episode of care
640.03
Threatened abortion, antepartum
640.83
Other specified hemorrhage in early pregnancy, antepartum
640.93
Unspecified hemorrhage in early pregnancy, antepartum
641.03
Placenta previa without hemorrhage, antepartum
641.13
Hemorrhage from placenta previa, antepartum
641.23
Premature separation of placenta, antepartum
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641.93
Unspecified antepartum hemorrhage
642.03
Antepartum benign essential hypertension
642.13
Hypertension sec to renal disease, antepartum
642.23
Other pre-existing hypertension, antepartum
642.33
Antepartum transient hypertension
642.43
Mild or unspecified pre-eclampsia, antepartum
642.53
Severe pre-eclampsia, antepartum
642.63
Eclampsia, antepartum
642.73
Pre-eclampsia/eclampsia pre-exist htn, antepartum
644.03
Threatened premature labor, antepartum
644.13
Other threatened labor, antepartum
645.13
Post -term pregnancy, antepartum condi/comp
645.23
Prolonged pregnancy delivered, antepartum condi/comp
646.23
Unspecified antepartum renal disease
646.33
Habitual aborter antepartum condi/comp
646.73
Liver disorders antepartum
646.83
Other specified antepartum complications
646.93
Unspecified antepartum complications
647.03
Maternal syphilis, antepartum
647.33
Maternal tuberculosis, antepartum
647.63
Other antepartum viral diseases
648.03
Antepartum diabetes mellitus
648.13
Maternal thyroid dysfunction, antepartum condi/comp
648.23
Maternal anemia, antepartum
648.33
Maternal drug dependence, antepartum
648.43
Maternal mental disorders, antepartum
648.46
Antepartum mental disorders of mother
648.53
Maternal congenital cv disorders, antepartum
648.63
Other maternal cardiovascular diseases, antepartum
648.83
Abnormal specified antepartum complications
648.93
Other current conditions classifiable elsewhere of mother, antepartum
651.03
Twin pregnancy, antepartum condi/comp
651.13
Triplet pregnancy, antepartum
651.23
Quadruplet pregnancy, antepartum
651.83
Other specified multiple gestation, antepartum
651.93
Unspecified multiple gestation, antepartum
652.23
Breech presentation without version, antepartum
653.53
Unusually large fetus causing disproprtn, antepartum
654.13
Tumors of body of uterus, antepartum condi/comp
654.53
Cervical incompetence, antepartum condi/comp
654.63
Other congenital or acquired abnormality of cervix, antepartum condi/comp
655.03
Central nervous system malformation in fetus, antepartum
655.13
Chromosomal abnormality in fetus affecting management of mother, antepartum
Hereditary disease in family possibility affecting fetus affecting management of mother,
antepartum condi/comp
655.23
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655.33
655.43
Spct damage fetus viral dz mom, antepartum compl
Suspected damage to fetus from other disease in the mother affecting management of
mother, antepartum condi/comp
655.53
Suspected damage to fetus from drugs affecting management of mother, antepartum
655.63
Spct damage fetus rad mgmt moth, antepartum condi/comp
655.73
655.93
Decreased fetal movement affecting management of mother, antepartum condi/comp
Other known or suspected fetal abnormality affecting management of mother; unspecified
as to episode of care
Unspecified suspected fetal abnormality affecting management of mother; unspecified as to
episode of care
Unspecified suspected fetal abnormality affecting management of mother, antepartum
condi/comp
656.13
Rhesus isoimmun affct mgmt moth, antepartum condi
656.23
Isoimmu uns bld-grp incompat management of mother, antepartum
656.4
Intrauterine death affecting management of mother
656.43
Intrauterine death affect management of mother, antepartum
656.53
Poor fetal growth affecting management of mother; unspecified as to episodes of care
656.63
Excessive fetal growth affecting management of mother, antepartum
656.80
Other spec fetl&placntl probs management of mother; uns eoc
656.81
Other spec fetal&placntl probs management of mother, delivery
656.83
Other specified fetal and placental problems affecting management of mother, antepartum
656.93
Unspecified fetal and placental problem affecting management of mother, antepartum
657.03
Polyhydramnios, antepartum complication
658.03
Oligohydramnios, antepartum
658.13
Premature rupture of membranes, antepartum
658.23
Delayed delivery after spontaneous or unspecified rupture of membranes, antepartum
659.43
Grand multiparity w/current pregnancy, antepartum
659.53
Elderly primigravida, antepartum
659.60
Elder multigravida; uns as epis care/not applic
659.63
Other advanced maternal age, antepartum condi/comp
659.73
Abnormality in fetal heart rate or rhythm, antepartum condi/comp
671.23
Superficial thrombophlebitis , antepartum
671.33
Deep phlebothrombosis, antepartum
671.53
Other antepartum phlebitis and thrombosis
789.01
Abdominal pain, right upper quadrant
789.02
Abdominal pain, left upper quadrant
789.03
Abdominal pain, right lower quadrant
789.04
Abdominal pain, left lower quadrant.
789.05
Abdominal pain, periumbilic
789.06
Abdominal pain, epigastric
789.07
Abdominal pain, generalized
789.08
Abdominal pain
789.09
Abdominal pain, other specified site
V23.2
Supervision of high-risk pregnancy with history of abortion
V23.41
Supervision of high-risk pregnancy with history of preterm labor
V23.49
Supervision of high-risk pregnancy with other poor obstetric history
655.83
655.9
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V23.5
Supervision of high-risk pregnancy with other poor reproductive history
Vv23.7
Supervision of high-risk pregnancy with insufficient prenatal care
V23.82
Supervision high-risk pg elder multigravida
V23.89
Supervision of other high-risk pregnancy
V23.9
Supervision of unspecified high-risk pregnancy
V28.4
Antenatal screening for fetal growth retardation using ultrasonics
V28.82
Encounter for screening for risk preterm labor
Appendix B
Policy Updates
2010 – 2011
Updates for all markets except Florida
76811: 656.83, 659.60, V28.82
76815: 642.03, 642.23, 642.33, 655.93, 656.53
76816: 656.81, 656.83
76817: V28.82
Exclusions of maternal/fetal medicine providers using specialty codes S142, S083, S055, S088;
radiologist codes S164 and S232; and POS code 23 (emergency department).
Florida updates
76811: Pay only these provider specialty types: Radiology (S164), Maternal/Fetal (S083) and
Freestanding Radiology Facility (S165).
Appendix A updates
Additional codes: 648.23, 648.43, V23.82, 659.60, 218.9, 656.4, 651.13, 651.83, 651.93,
656.80, 656.81, 651.23, 199.0, 199.1, 648.13, 493.00–493.91, 042, 345.00–345.91,
282.0–282.9, 648.53, 648.63, 671.23, 671.33, 671.56, 656.13, 642.53, 642.63, 642.73, 642.13,
648.33, 656.23, 655.33, 655.63, 659.43, 647.33, 646.73, 646.23, 647.03, 653.53, 656.43,
645.13, 645.23, 789.01–789.03, 789.05–789.09
Deleted Codes: 654.13, 644.13
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