OB Ultrasound Authorization and Coding Guide Ultrasound Limited, follow-up transabdominal and...

Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015 1

OB Ultrasound Authorization and Coding Guide

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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 ObstetricalGEMS2 (only 1 use in 1st Trimester [ < 14 weeks])

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 ObstetricalYes 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

76821Doppler velocimetry, fetal; middle cerebral artery

Yes

76825Echocardiography, fetal, cardiovascular system, initial

Yes

76826Echocardiography, fetal, cardiovascular system, follow up

Yes

76827 Doppler echocardiography, initial Yes

76828 Doppler echocardiography, follow up Yes

93325Doppler echocardiography color flow velocity

Yes

59000-76946 Amniocentesis-OB U/S Guided Yes

* GEMS stands for “Getting Early Maternity Services”



A. Indications for a Detailed, Limited and Follow-up UltrasoundLimited, follow-up transabdominal and transvaginal obstetric ultrasounds will be approved for fetal, obstetrical or maternal complications.

B. Indications for Biophysical ProfileA biophysical profile is indicated when an appropriate, approved medical condition is present.

C. Indications for a Vessel DopplerSpecialty 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 EchoAccording 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.



Absence or hypoplasia of umbilical artery

ICD 10 Indications

Q27.0

Advanced maternal age

ICD 10 Indications

O09.519 - O09.523 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

O41.**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.

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)

Table 3: Diagnostic Codes related to Maternal/Fetal Conditions (not all-inclusive)

** Indicates multiple code variations for the diagnosis



Asthma

ICD 10 Indications

J45.** Severe, documented asthma requiring daily medication such as long-acting beta-agonist and/or inhaled or oral steroids.

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


Endocardial fibroelastosis


Alcoholic cardiomyopathy


Cardiomegaly


Congenital cardiovascular disorders

Q24.9 Documented diagnosis affecting maternal-fetal condition during pregnancy



Cardiac (continued)

ICD 10 Indications

Other cardiovascular diseases


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


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




Cardiac (continued)

ICD 10 Indications

Other cardiovascular diseases


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


Abnormality in fetal heart rate or rhythm, unspecified as to time of onset, affecting fetus or newborn


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


Cervical Length Screening

ICD 10 Indications

O26.879 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 Indications

O26.619 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



Decreased Fetal Movement

ICD 10 Indications

O36.81** 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

Z79.4 Diabetes diagnosed prior to pregnancy requiring medication (e.g. insulin, glyburide) to control.

Drug/ETOH abuse, or methadone use/abuse

ICD 10 Indications

F10-F16.**, F18-F19.** 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



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


Hereditary disease in family possibly affecting fetus affecting management of mother, antepartum condition or complication


Suspected damage to fetus from viral disease in mother, antepartum condition or complication




Fetal Abnormality (continued)

ICD 10 Indications

Suspected damage to fetus from other disease affecting management of mother, antepartum condition or complication


Suspected damage to fetus from drugs affecting management of mother, antepartum condition or complication


Other known or suspected fetal abnormality, not elsewhere classified, antepartum condition or complication


Unspecified known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, antepartum condition or complication


Other nonspecific abnormal findings on radiological and other examination of body structure

R93.8 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.

Poor fetal growth affecting management of mother

O36.5***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.

Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication

ICD 10 Indications

O43.011 Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication (ex. vasa previa)

Fetal size/due date discrepancy

ICD 10 Indications

O26.84 A significant discrepancy of 3 or more between fundal height (centimeters) to gestational age (weeks).



Fetus or newborn affected by placental transfusion syndromes

ICD 10 Indications

P02.3, O43.0, P50.3 Fetus or newborn affected by placental transfusion syndromes

Hereditary hemorrhagic telangiectasia

ICD 10 Indications

I78.0 Hereditary hemorrhagic telangiectasia

Hydrocephalic fetus causing disproportion, antepartum condition or complication

ICD 10 Indications

O33.6XX0 Hydrocephalis

Hydrops fetalis not due to isoimmunization, fetus or newborn

ICD 10 Indications

P83.2 Hydrops fetalis not due to isoimmunization, fetus or newborn

Hypertension, chronic

ICD 10 Indications

O10.**, I11.** 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 Indications

O99.28* Uncontrolled, defined by suppressed TSH level with related maternal symptoms.

Hypothyroid disease, maternal

ICD 10 Indications

O99.28* Uncontrolled, defined by elevated thyroid stimulating hormone (TSH) and related maternal symptoms.

Human Immunodeficiency Virus (HIV) infection, maternal

ICD 10 Indications

098.7* Confirmed HIV, documented in chart.



Incompetent cervix and no cerclage

ICD 10 Indications

034.**, N88.3 Premature opening of the cervix.

Increased nuchal translucency

ICD 10 Indications

Z36 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

O98.91* Unspecified infection or infestation of mother, antepartum condition or complication

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 Indications

O09.211 Documented history of IUFD.

Intrauterine Growth Restriction (IUGR)

ICD 10 Indications

P05.9Estimated 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.



Malpresentation

ICD 10 Indications

032.*** Presentation other than vertex after 36 weeks.

Mental disorders complicating pregnancy, antepartum condition or complication

ICD 10 Indications

O99.34* Mental disorders complicating pregnancy, antepartum condition or complication

MSAFP (Maternal serum alpha-fetoprotein) level, elevated

ICD 10 Indications

Z36 Unexplained, elevated MSAFP, > 2.5 MoMs (quantitative unit of measure for MSAFP reported as multiples of the median).

Multiple gestations

ICD 10 Indications

O30-O31.** 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



Obesity in pregnancy

ICD 10 Indications

O99.21* 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 Indications

Z36 Other specified antenatal screening

Other specified complications of pregnancy, antepartum condition or complication

ICD 10 Indications

O26.1**, O26.4**, O26.8** Other specified complications of pregnancy, antepartum condition or complication

PAPP-A (Pregnancy-associated plasma protein A), abnormal value

ICD 10 Indications

O35.** Unexplained, <0.3 MoMs (multiples of the median).

Phenylketonuria

ICD 10 Indications

E70.1 Phenylketonuria

Placenta previa

ICD 10 Indications

O44.** Asymptomatic (without bleeding) with documented prior ultrasound report of placenta located near or over the internal cervical orifice.

Placental abruption

ICD 10 Indications

O45.** Vaginal bleeding with suspected placental abruption.

Post term pregnancy

ICD 10 Indications

O48.** Pregnancy that is at or beyond forty (40) weeks of gestation



Pre-eclampsia

ICD 10 Indications

O10.*** and additional codes

New onset of blood pressure elevation exceeding 140/90 mm Hg after twenty (20) weeks gestation.

Pregnancy resulting from assisted reproductive technology

ICD 10 Indications

O09.819 Pregnancy resulting from assisted reproductive technology

Premature rupture of membranes

ICD 10 Indications

O42.0** Confirmed and documented in chart.

Pre-term delivery history

ICD 10 Indications

Z87.51 Patient has had a previous pregnancy that delivered between 20 and 37 weeks of gestation.

Pre-term delivery risk screening of low-risk patient (cervical shortening)

ICD 10 Indications

N88.3 Documented concern that supports need for transvaginal ultrasound to screen for cervical length shortening.

Pre-term labor

ICD 10 Indications

O60.1*** 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



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 Indications

O26.839 Documented history of parenchymal renal disease prior to pregnancy.

Rheumatoid arthritis

ICD 10 Indications

M06.9 Rheumatoid arthritis

Rubella exposure

ICD 10 Indications

B06.9 Rubella exposure

Screening for malformation using ultrasonics [when reported alone - indicates routine screen without signs or symptoms]

ICD 10 Indications

Z36 Screening for malformation using ultrasonics [when reported alone - indicates routine screen without signs or symptoms]



Sicca syndrome (Sjörgen’s syndrome)

ICD 10 Indications

M35 Sicca syndrome

Sickle cell disease, maternal

ICD 10 Indications

D57.1 Documented maternal sickle cell disease (not just trait)

Systemic sclerosis

ICD 10 Indications

M34 Systemic sclerosis

Teratogen (eg. Retinoid) exposure

ICD 10 Indications

Z20 Teratogen (eg. Retinoid) exposure

Unspecified diffuse connective tissue disease

ICD 10 Indications

L94.9 Unspecified diffuse connective tissue disease

Vaginal bleeding

ICD 10 Indications

N93.9, O20.0 Suspected placental abruption, suspected placenta previa, suspected spontaneous abortion, etc.



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]



ReferencesAmerican 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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