1.0 CPT
PROCEDURE CODE RANGES
Diagnostic Ultrasound:
76506 - 76776, 76800 - 76886
Ultrasonic
Guidance: 76930 - 76965
Ultrasound
Other: 76970 - 76999
3.0 POLICY
3.1 Ultrasound
procedures for diagnosis, guidance, and post-operative evaluation
of surgical procedures may be cost-shared.
3.2 Maternity related ultrasound.
Professional and technical components of medically necessary fetal
ultrasounds are covered outside the maternity global fee. The medically
necessary indications include (but are not limited to) clinical
circumstances that require obstetric ultrasounds to: estimate gestational
age, evaluate fetal growth, conduct a biophysical evaluation for
fetal well being, evaluate a suspected ectopic pregnancy, define
the cause of vaginal bleeding, diagnose or evaluate multiple gestations,
confirm cardiac activity, evaluate maternal pelvic masses or uterine
abnormalities, evaluate suspected hydatidiform mole, and evaluate
the fetus’ condition in late registrants for prenatal care.
3.3 Bone Density
studies (Current Procedural Terminology (CPT) procedure code 76977)
are covered for:
3.3.1 The diagnosis and monitoring of osteoporosis.
3.3.2 For the
diagnosis and monitoring of osteopenia.
3.3.3 Patients must present with
signs and symptoms of bone disease or be considered at high-risk
for developing osteoporosis. High-risk factors for osteoporosis
are those identified as the standard of care by the American College
of Obstetricians and Gynecologists (ACOG).
4.0 EXCLUSIONS
4.1 Ultrasound
for routine screening for breast disease.
4.2 Ultrasound performed solely
to determine the sex of an unborn child for non-medical reasons.
4.3 Bone density
studies for routine screening for osteoporosis.
4.4 Ultrasound,
spinal canal and contents (CPT procedure code 76800) for spinal
scanning in adults for inflammatory conditions of the spine and
nerve roots or as guidance for facet joint or epidural injections
(CPT procedure codes 76881 and 76942).
4.5 3D and 4D rendering (CPT procedure
codes 76376 and 76377) with maternity ultrasound is unproven.