QUEST Integration – Ultrasound

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA covers ultrasound when medically indicated. Ultrasound for the sole purpose of gender determination is not covered.

Ultrasound may be billed separately from the global maternity fee for the following indications developed by the American College of Obstetricians and Gynecologists (ACOG) and adopted by HMSA:

• Estimation of gestational age for patients with uncertain clinical dates, or verification of dates for patients who are to undergo scheduled elective repeat cesarean delivery, induction of labor or elective termination of pregnancy.
• Evaluation of fetal growth.
• Vaginal bleeding of undetermined etiology during pregnancy.
• Determination of fetal presentation.
• Suspected multiple gestation.
• Adjunct to amniocentesis.
• Significant uterine size and clinical dates discrepancy.
• Pelvic mass.
• Suspected hydatidiform mole.
• Adjunct to cervical cerclage placement.
• Suspected ectopic pregnancy.
• Adjunct to special procedures.
• Suspected fetal death.
• Suspected uterine abnormality.
• Intrauterine contraceptive device localization.
• Biophysical evaluation for fetal well-being.
• Observation of intrapartum events.
• Suspected polyhydramnios or oligohydramnios.
• Suspected placental abruption.
• Adjunct to external version from breech to vertex presentation.
• Estimation of fetal weight and/or presentation in premature rupture of membranes and/or premature labor.
• Abnormal serum alpha-fetoprotein value.
• Follow-up observation of an identified fetal anomaly.
• Follow-up evaluation of placental location for identified placenta previa.
• History of previous congenital anomaly.
• Serial evaluation of fetal growth in multiple gestation.
• Evaluation of fetal condition in late registrants for prenatal care.

Note: Please do not submit separate claims for ultrasound performed as an adjunct to amniocentesis, cerclage placement, amnioscopy/fetoscopy or external version. Ultrasound is considered an integral part of these procedures.

Exceptions

There may be other conditions for which ultrasound may be appropriate. If you believe ultrasound to be appropriate in a specific clinical situation, please submit information for ordering or performing the service with your claim for review.

Referral Requirements

Ultrasound procedures within the 70000-79999 range of CPT codes do not require referral. Color Doppler (procedure 93325) billed with ultrasound procedure codes 76825, 76826, 76827 or 76828 does not require referral. However, if billed in conjunction with any other procedure, referral for the color Doppler will be required.

Revision History