Obstetrical Ultrasonography 76825

User Manual: 76825

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Obstetrical Ultrasonography

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UnitedHealthcare Oxford Clinical Policy

Effective 12/01/2017

OBSTETRICAL ULTRASONOGRAPHY

Policy Number: RADIOLOGY 013A.21 T2

Effective Date: December 1, 2017

Table of Contents Page

INSTRUCTIONS FOR USE .......................................... 1

CONDITIONS OF COVERAGE ...................................... 1

BENEFIT CONSIDERATIONS ...................................... 2

COVERAGE RATIONALE ............................................. 2

APPLICABLE CODES ................................................. 3

BACKGROUND ......................................................... 4

REFERENCES ........................................................... 4

POLICY HISTORY/REVISION INFORMATION ................. 5

INSTRUCTIONS FOR USE

This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do

not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as

necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term

Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member

specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan

Description (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the

event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first

identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan

coverage prior to use of this Clinical Policy. Other Policies may apply.

UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in

administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent

professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or

medical advice.

CONDITIONS OF COVERAGE

Applicable Lines of Business/ Products

This policy applies to Oxford Commercial plan membership.

Benefit Type

General benefits package

Referral Required

(Does not apply to non-gatekeeper products)

Authorization Required

(Precertification always required for inpatient

admission)

No1, 2

Precertification with Medical Director Review

Required

Applicable Site(s) of Service

(If site of service is not listed, Medical Director

review is required)

Home, Outpatient, Office

Special Considerations

1The fourth and subsequent ultrasound procedures per

pregnancy require precertification for participating providers as

outlined in this policy by eviCore healthcare.

2Refer to the Benefits Consideration section for precertification

guidelines for New Jersey (NJ) Small group plans, NJ Individual

plans (for Date of Service (DOS) prior to 01/01/17, NJ School

Board plans and NJ Municipality plans.

Related Policy

 Radiology Procedures Requiring Precertification for

eviCore healthcare Arrangement

UnitedHealthcare® Oxford

Clinical Policy

Obstetrical Ultrasonography

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UnitedHealthcare Oxford Clinical Policy

Effective 12/01/2017

BENEFIT CONSIDERATIONS

Before using this policy, please check the member specific benefit plan document and any federal or state mandates,

if applicable.

New Jersey (NJ) Small, NJ Individual (for Date of Service (DOS) prior to 01/01/17), NJ School Board and

NJ Municipality Products

Services indicated as requiring a precertification require medical necessity review. This review may be requested prior

to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review

will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to

rendering the service. It is the referring physician’s responsibility to provide medical documentation to demonstrate

clinical necessity for the study that is being requested (for review prior to service) or has been rendered (for review

after service was provided).

Essential Health Benefits for Individual and Small Group

For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured

non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten

categories of Essential Health Benefits (“EHBs”). Large group plans (both self-funded and fully insured), and small

group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to

provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be

removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is

made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit

plan document to determine benefit coverage.

COVERAGE RATIONALE

This policy has three components:

1. Utilization Management

Participating Providers will be reimbursed in accordance to their contract, for up to three ultrasounds per pregnancy,

based upon their specialty and applicable payment rules, without precertification as outlined in section II and III of

this policy.

The fourth and subsequent obstetrical ultrasound procedure per Member per pregnancy performed by a participating

provider as outlined are subject to utilization review (pre-certification) by eviCore healthcare.

Oxford has engaged eviCore healthcare to perform initial reviews of requests for pre-certification and Medical

necessity reviews. To pre-certify a radiology procedure, please call eviCore healthcare at 1-877-PRE-AUTH (1-877-

773-2884) or log on to the eviCore healthcare web site using the Prior Authorization and Notification App.

eviCore healthcare has established an infrastructure to support the review, development, and implementation of

comprehensive outpatient imaging criteria. The radiology evidence-based guidelines and management criteria are

available on the eviCore healthcare web site: http://www.carecorenational.com/page/criteria.aspx.

2 & 3. Payment by Specialty & Accreditation/Certification Requirements

Specialists will be reimbursed for radiology services rendered in the office, outpatient or home setting. Services are

payable to participating physicians based on their specialty. In addition, certain ultrasounds may not be reimbursed

unless the providers hold a particular accreditation.

a. Reproductive Endocrinologists may perform the following ultrasound CPT codes; precertification for the fourth and

subsequent procedures per Member per pregnancy is required:

 76815, 76816, 76817

*In addition to the codes listed above a Reproductive Endocrinologist, with an AIUM/ACR accreditation may

perform the following studies; precertification for the fourth and subsequent procedure per Member per

pregnancy is required:

 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826,

76827, 76828

b. Obstetricians/Gynecologists may perform the following ultrasound CPT codes; precertification for the fourth and

subsequent procedure per Member per pregnancy is required:

 76815, 76816, 76817

*In addition to the codes listed above an Obstetrician/Gynecologist, with an AIUM or ACR accreditation may

perform the following studies; precertification for the fourth and subsequent procedure per Member per

pregnancy is required:

Obstetrical Ultrasonography

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UnitedHealthcare Oxford Clinical Policy

Effective 12/01/2017

 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826,

76827, 76828

c. Maternal Fetal Medicine and Perinatal Neonatal Medicine specialists may perform the following ultrasound CPT

codes; precertification for the fourth and subsequent procedure per Member per pregnancy is required:

 76815, 76816, 76817

*In addition to the codes listed above a Maternal Fetal Medicine and Perinatal Neonatal Medicine specialist,

with an AIUM or ACR accreditation may perform the following studies, precertification for the fourth and

subsequent procedure per Member per pregnancy is required:

 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76818, 76819, 76820, 76821, 76825, 76826,

76827, 76828

d. Board Certified Pediatric Cardiologists with the American Board of Pediatrics and Cardiology Laboratories

accredited by the Intersocietal Accreditation Commission for Echocardiography may perform the following

ultrasound CPT codes; precertification for the fourth and subsequent procedure per Member per pregnancy is

required:

 76825-76828

APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all

inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-

covered health service. Benefit coverage for health services is determined by the member specific benefit plan

document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply

any right to reimbursement or guarantee claim payment. Other Policies may apply.

Payment guidelines are applicable to participating providers only.

 CPT code 76805 will be reimbursed two times per pregnancy if billed by two different providers and the provider

has not already billed a 76811 - if 76805 is billed multiple times, claim(s) will be denied and provider will need to

resubmit claim(s) with the correct CPT code (76815 or 76816).

 CPT code 76810 will be reimbursed one time per fetus - if 76810 is billed more than one time per fetus, claim(s)

will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816).

 CPT code 76811 will be reimbursed two times per pregnancy if billed by two different providers. If 76811 is

billed multiple times by the same provider, claim(s) will be denied and provider will need to resubmit claim(s) with

the correct CPT code (76815 or 76816).

 CPT code 76812 will be reimbursed one time per fetus - if 76812 is billed is billed more than one time per fetus,

claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76815 or 76816).

 CPT code 76813 will be reimbursed one time per pregnancy for a single fetus or first of a multiple gestation.

 CPT code 76814 will be reimbursed (in addition to CPT code 76813) one time per pregnancy for each additional

fetus of a multiple gestation.

 CPT code 76820 will be reimbursed one time per fetus per date of service.

 CPT code 76821 will be reimbursed one time per fetus per date of service.

 CPT code 76825 will be reimbursed one time per fetus - if 76825 is billed is billed more than one time per fetus,

claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76826).

 CPT code 76827 will be reimbursed one time per fetus - if 76827 is billed is more than one time per fetus,

claim(s) will be denied and provider will need to resubmit claim(s) with the correct CPT code (76828).

 Evaluation and management (E&M) codes will be reimbursed on the same date of service as an obstetrical

ultrasound only when the service is separate and distinct from routine antepartum care, as indicated by appending

modifier -25.

CPT Code

Description

76801

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or

first gestation

76802

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each

additional gestation (List separately in addition to code for primary procedure)

76805

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach;

single or first gestation

76810

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach;

each additional gestation (List separately in addition to code for primary procedure)

Obstetrical Ultrasonography

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UnitedHealthcare Oxford Clinical Policy

Effective 12/01/2017

CPT Code

Description

76811

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation plus detailed fetal anatomic examination, transabdominal approach; single

or first gestation

76812

Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal

evaluation plus detailed fetal anatomic examination, transabdominal approach; each

additional gestation (List separately in addition to code for primary procedure)

76813

Ultrasound, pregnant uterus, real time with image documentation, first trimester

fetal nuchal translucency measurement, transabdominal or transvaginal approach;

single or first gestation

76814

Ultrasound, pregnant uterus, real time with image documentation, first trimester

fetal nuchal translucency measurement, transabdominal or transvaginal approach;

each additional gestation (List separately in addition to code for primary procedure)

76815

Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal

heartbeat, placental location, fetal position, and/or qualitative amniotic fluid volume),

one or more fetuses

76816

Ultrasound, pregnant uterus, real time with image documentation, follow up (e.g.,

re-evaluation of fetal size by measuring standard growth parameters and amniotic

fluid volume, re-evaluation of organ system(s) suspected or confirmed to be

abnormal on a previous scan), trans abdominal approach per fetus.

76817

Ultrasound, pregnant uterus, real time with image documentation, transvaginal; for

non-obstetrical transvaginal ultrasound use 76830; If transvaginal examination is

done in addition to transabdominal obstetrical ultrasound exam, use 76817 in

addition to appropriate transabdominal exam code.

76818

Fetal biophysical profile; with non-stress testing

76819

Fetal biophysical profile; without non-stress testing

76820

Doppler velocimetry, fetal; umbilical artery

76821

Doppler velocimetry, fetal; middle cerebral artery

76825

Echocardiography, fetal, cardiovascular system, real time with image documentation

(2D) with or without M-mode recording

76826

Echocardiography, fetal, cardiovascular system, real time with image documentation

(2D) with or without M-mode recording; follow up or repeat study

76827

Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral

display; complete

76828

Doppler echocardiography, fetal pulsed wave and/or continuous wave with spectral

display; follow up or repeat study

CPT® is a registered trademark of the American Medical Association

BACKGROUND

Obstetric Ultrasound is a highly developed technique used to detect ectopic pregnancy and multiple pregnancies,

assessing fetal life and function, diagnosing physical anomalies, and guiding physicians in their efforts to treat the

fetus.

Although the clinical benefit of routine ultrasonography has not been established, it is commonly performed early in

pregnancy for confirmation of dates, fetal viability, and pregnancy location. Later studies at 16-20 weeks are used to

assess fetal anatomy and to identify potential fetal abnormalities. In addition, there are a variety of complications that

require ultrasound for evaluation.

REFERENCES

American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins - Obstetrics.

Ultrasonography in pregnancy. ACOG Practice Bulletin No. 58. Washington, DC: ACOG; December 2004.

American College of Obstetricians and Gynecologists. Ultrasonography in Pregnancy. Technical Bulletin no. 187, 1993.

American Institute of Ultrasound in Medicine: Standards of Performance. Antepartum Obstetrical Ultrasound

Examination.

American Medical Association. Current Procedural Terminology: CPT Professional Edition.

Obstetrical Ultrasonography

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UnitedHealthcare Oxford Clinical Policy

Effective 12/01/2017

Lefevre ML, Bain RP, Ewigman BG et al. A randomized trial of prenatal ultrasonographic screening: impact on maternal

management and outcome. The RADIUS Study Group. Am.J. Obstet Gynecol 1993; 169:483-489.

National Institutes of Health Consensus Development Conference. The use of diagnostic ultrasound imaging during

pregnancy. JAMA 1984, 252: 669-672.

Society for Maternal-Fetal Medicine (SMFM), Coding Committee. White paper on ultrasound code 76811.

Announcements. Washington, DC: SMFM; May 24, 2004. Available at: www.smfm.org.

POLICY HISTORY/REVISION INFORMATION

Date

Action/Description

12/01/2017

 Updated language pertaining to the precertification request process; added

reference link to the Prior Authorization and Notification App

 Archived previous version RADIOLOGY 013A.20 T2

Obstetrical Ultrasonography 76825

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