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.