Coverage Policy Manual
Policy #: 1998061
Category: Radiology
Initiated: February 1998
Last Review: August 2018
  Ultrasound in Maternity Care

Description:
Ultrasound is the transmission of high-frequency sound waves through tissues of varying densities. The echoes produced by the sound waves at interfaces between tissues are transmitted by piezoelectric crystals within a transducer. The transducer is a hand-held device passed over the abdominal surface. Images created by the echoes of the sound waves are transmitted from the transducer to a CRT or television monitor. Advances in ultrasound technology enable evaluations and measurement of fetal characteristics and organ systems in much greater detail.
 
Obstetric ultrasound is coded depending on the gestational age and the performance of elements included in the CPT code description.
A study for a gestation of less than 14 weeks 0 days (76801, 76802) includes:
    • determination of the number of gestational sacs and fetuses,
    • gestational sac/fetal measurements appropriate for gestation,
    • survey of visible fetal and placental anatomic structure,
    • qualitative assessment of amniotic fluid volume/gestational sac shape, and
    • examination of the maternal uterus and adnexa.  
 
An ultrasound for a gestation of 14 weeks 0 days or longer (76805, 76810) includes:
    • determination of number of fetuses and amniotic/chorionic sacs, measurements appropriate for gestational age,
    • survey of intracranial/spinal/abdominal anatomy, 4 chambered heart, umbilical cord insertion site, placenta location,
    • amniotic fluid assessment and,
    • when visible, examination of maternal adnexa.
 
The report of the ultrasound should document the results of the evaluation of each of the elements described above or the reason for the nonvisualization.
 
New technology now allows a more extensive evaluation and anatomical fetal survey when the standard maternal ultrasound has identified fetal or maternal abnormalities, or studies of maternal blood (serum triple screen) or amniotic fluid have suggested potential fetal abnormalities.  
 
More detailed obstetric ultrasound studies (76811, 76812) include all elements of the codes above AND detailed anatomic evaluation of:
    • the fetal brain/ventricles, face, heart/outflow tracts and chest anatomy,
    • abdominal organ specific anatomy,
    • number/length/architecture of limbs,
    • detailed evaluation of the umbilical cord and placenta, and
    • other fetal anatomy as clinically indicated.  
 
Coverage for fetal nuchal translucency measurement is found in policy # 2004016.

Policy/
Coverage:
Ultrasound is not medically necessary in every pregnancy.   A routine ultrasound performed in normal obstetrical prenatal care may be covered once but this is dependent on contract benefit language.  A routine ultrasound in normal obstetrical prenatal care is an exclusion in some contracts.
 
The American College of Obstetrics and Gynecology (ACOG) lists the following indications for the use of first trimester ultrasound:
    • to confirm the presence of an intrauterine pregnancy and estimation of gestational age;
    • to evaluate a suspected ectopic pregnancy;
    • to define the cause of vaginal bleeding;
    • to evaluate pelvic pain;
    • to diagnose or evaluate multiple gestations;
    • to confirm cardiac activity;
    • as an adjunct to chorionic villus sampling, embryo transfer, or localization and removal of an intrauterine abnormalities;
    • to evaluate suspected hydatiform mole.
 
ACOG indications for the use ultrasound after the first trimester include:   
    • Suspected ectopic pregnancy;
    • Suspected hydatidiform mole;
    • Threatened or missed abortion;
    • Congenital malformation, fetal or maternal;
    • Polyhydramnios/oligohydramnios;
    • Placenta previa;
    • Suspected multiple gestation;
    • Significant discrepancy between uterine size and dates;
    • evaluation of abnormal serum screening value,
    • evaluation of significant  uterine size and clinical date discrepancy;
    • determination of fetal presentation;
    • Suspected fetal death;
    • Suspected anatomical uterine abnormality;
    • Maternal risk factors such as family history of congenital anomalies;
    • Suspected fetal growth abnormality, either growth retardation or macrosomia;
    • evaluation of fetal condition in late registrants for prenatal care;
    • follow-up of identified fetal anomaly.
 
Claims for obstetric ultrasounds must be supported by reports that include descriptions of all elements as indicated in the CPT Manual.
 
Ultrasound studies reported with 76815 and 76816 meet primary coverage criteria for effectiveness and are covered in circumstances as defined in the CPT code descriptors.  
 
A transvaginal ultrasound done on the same day as a transabdominal ultrasound of a pregnant uterus will result in decreased payment of the technical component of the code with lesser RVUs.

Rationale:
2015 Update
A literature search conducted through July 2015 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Bruns and colleagues performed a prospective cross-sectional study to determine the applicability of pocket ultrasound as a complementary method for clinical evaluation during the first trimester of pregnancy (Bruns, 2015). The study was conducted with 86 pregnant women attended in an emergency. The same operator performed the first examination with pocket device Vscan (General Electric, Vingmed Ultrasound, Horten, Norway) and then repeated the exam using a traditional handset high resolution Voluson 730 Expert (General Electric Healthcare Ultrasound, Milwaukee, WI, USA). Data were recorded with individual diagnoses by means of yes/no binary as the visualization of variables: gestational sac, embryo, embryo heartbeat, topical or ectopic pregnancy. Concordance was calculated using the kappa coefficient with its respective 95% confidential intervals (CI). There was no disagreement between the methods when compared the pocket and conventional ultrasounds. The best comparative result between the devices was as the visualization of the embryo heartbeat with kappa coefficient of 0.84 (95% CI 0.76 to 0.89). However, the pocket ultrasound had a low correlation for diagnosis of ectopic pregnancy, with kappa coefficient of -0.02 (95% CI -0.23 to 0.19). The smaller structure visualized and studied using the pocket ultrasound was an embryo of 3.4 mm. The method of pocket ultrasound has the potential to become a complementary and easy access for diagnostic tool in obstetric patients during the first trimester. However, in ectopic pregnancy cases the diagnosis should be realized by conventional ultrasound.
 
A study by Aksoy and colleagues was identified with the aim to investigate standard biometric measurements, such as biparietal diameter (BPD), femur length (FL), abdominal circumference (AC), estimated fetal weight (EFW) and anterior abdomen wall thickness (AAWT) in fetuses complicated by gestational diabetes mellitus (GDM) at the time of GDM screening, and to compare the results with healthy pregnant controls (Aksoy, 2015).  A total of 124 pregnant women between 26 and 28 weeks' gestation were included in the study. These patients were divided into two groups based on their 75-g oral glucose tolerance test results. The study group consisted of 55 pregnant women with GDM, and 69 healthy pregnant women constituted our control group. The study groups did not differ with respect to the mean BPD, FL, AC and EFW; however, the mean AAWT was significantly higher in the GDM group, 4.07 ± 0.46 mm versus 3.28 ± 0.37 mm in the control group (p < 0.001). The only fetal sonographic measurement found to significantly differ between the study groups was the AAWT in 26 weeks at the time of gestational diabetes screening, suggesting that measuring the AAWT may have a role in the evaluation of fetal growth in pregnancies complicated by gestational diabetes.
 
2018 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2018. No new literature was identified that would prompt a change in the coverage statement.
 

CPT/HCPCS:
76801Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (&lt; 14 weeks 0 days), transabdominal approach; single or first gestation
76802Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (&lt; 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)
76805Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (&gt; or = 14 weeks 0 days), transabdominal approach; single or first gestation
76810Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (&gt; or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)
76815Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses
76816Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, 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), transabdominal approach, per fetus
76817Ultrasound, pregnant uterus, real time with image documentation, transvaginal

References: Aksoy H, Aksoy Ü, Yücel B, et al.(2015) Fetal anterior abdominal wall thickness may be an early ultrasonographic sign of gestational diabetes mellitus. J Matern Fetal Neonatal Med. 2015 Sep 3:1-5

American College of Obstetricians and Gynecologists (ACOG). Ultrasonography in pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Feb. 11 p. (ACOG practice bulletin; no. 101).

Berkowitz, RL.(1993) Should every pregnant woman undergo ultrasonography? NEJM 1993; 329:874-875. Letter.

Bruns RF, Menegatti CM, Martins WP, et al(2015) Applicability of pocket ultrasound during the first trimester of pregnancy. Med Ultrason. 2015 Sep;17(3):284-8.

Ewigman BG, et al.(1993) Effect of prenatal ultrasound screening on perinatal outcome. NEJM 1993; 329:821-827.

Ultrasonography in pregnancy. ACOG Practice Bulletin. Obstet Gynecol, 2004; 104:1449-58.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.