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TRICARE Policy Manual 6010.60-M, April 1, 2015
Chapter 5
Section 2.1
Diagnostic Ultrasound
Issue Date:  November 1, 1983
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Diagnostic Ultrasound: 76506 - 76776, 76800 - 76886
Ultrasonic Guidance: 76930 - 76965
Ultrasound Other: 76970 - 76999
The visualization of deep structures of the body by recording the reflections (echoes) of pulses of ultrasonic waves direct into the tissues. Ultrasound is used for diagnostic and guidance purposes.
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).
4.1  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.
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