1.0 CPT 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) 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 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 codes
76881 and 76942).
4.5 3D and
4D rendering (CPT codes 76376 and 76377) with maternity ultrasound
is unproven.