EviCore



Low Risk PregnancyPatient Name: DiagnosisDiagnosis, if known or rule out:ICD-10 Codes:Date of last visit: Clinical Information1. Patient Estimated Delivery Date (EDC):2. Patient age at EDC:3. Gravida (G) ________ Para (P) Term_____ Preterm_____ Abortion/Miscarriage_______ Living______4. Number of gestations (babies):5. What is the date of the first Obstetrical office visit for this pregnancy?6. Height _____ Weight_____ BMI________ 7. Fetal Nuchal Translucency is supported if cfDNA has not been completed or is not plannedNuchal translucency is completed between 11 and 13 6/7 weeks (CRL between 44 and 83 mm) ? CPT? 76813 Gestational age at time of imaging _____________8. Initial Screening for Fetal Anomalies Fetal Anatomy Scan – Optimally completed at ≥ 18 weeks, may be considered at ≥ 16 weeks ? CPT? 76805 Gestational age at time of imaging _____________9. Additional Factors Complicating Pregnancy: ? ______________________________________________________________________________ ? None To facilitate processing your request please submit relevant prenatal recordSubmitterWho is making this request?Ordering Physician Facility Other:Print Name:Title:MDRNLPNPANP Other:Signature: ................
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