EviCore Obstetrical Ultrasound Imaging Guidelines ...

CLINICAL GUIDELINES

OB Ultrasound Imaging Policy

Version 1.0 Effective February 14, 2020

eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual's Primary Care Physician (PCP) may provide additional insight. CPT? (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT? five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT? book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

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OB Ultrasound Imaging Guidelines

V1.0

Obstetrical Ultrasound Imaging Guidelines

Abbreviations and Glossary for OB Ultrasound Imaging Guidelines 6

OB-1: Obstetrical Ultrasound Imaging General Guidelines

7

OB-1.1: Required Documentation

8

OB-1.2: Inappropriate Use of OB Ultrasound

8

OB-1.3: Ultrasound Code Selection

8

OB-2: Uncertain Dates

10

OB-2.1: Uncertain Dates/Unknown Last Menstrual Period (LMP) 11

OB-3: Intrauterine Device (IUD)

12

OB-3.1: Locate an Intrauterine Device

13

OB-4: Infertility

14

OB-4.1: History of Infertility

15

OB-4.2: Present Pregnancy with ART Treatment (IVF)

15

OB-5: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping 16

OB-5.1: Abdominal Pain

17

OB-5.2: Vaginal Bleeding and/or Abdominal/Pelvic Pain

17

OB-5.3: Ectopic Pregnancy

18

OB-5.4: Spontaneous Abortion/Threatened/Missed Abortion

18

OB-5.5: Hydatidiform Mole

19

OB-6: Fetal Aneuploidy and Anomaly Screening

20

OB-6.1: First Trimester Screening

21

OB-6.2: Second Trimester Screening

22

OB-7: Fetal Anatomic Scan

24

OB-7.1: Initial Screening for Fetal Anomalies

25

OB-7.2: Fetal Anatomic Scan ? Follow-up

25

OB-8: Third Trimester Imaging

27

OB-8.1: Third Trimester Imaging ? Ultrasound

28

OB-9: High Risk Pregnancy

29

OB-9.1: High Risk Group One ? Risk Factors

31

OB-9.2: High Risk Group Two ? Findings on Ultrasound that May

Require Further Imaging

33

OB-9.3: High Risk Group Three ? BMI

34

OB-9.4: High Risk Group Four ? Macrosomia

36

OB-9.5: High Risk Group Five ? Zika Virus

37

OB-9.6: High Risk Group Six ? Pre-Gestational Diabetes

38

OB-9.7: High Risk Group Seven Gestational Diabetes

39

OB-9.8: Hypertension

40

OB-9.9: History of Pre-Term Delivery/History of PPROM

42

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OB Ultrasound Imaging Guidelines

V1.0

OB-9.10: History of Stillbirth

43

OB-10: High Risk Medications and Substances

47

OB-10.1: Medications and Substances that Qualify for a Detailed Fetal

Anatomic Scan

48

OB-11: Multiple Gestations

50

OB-11.1: For Suspected Multiple Gestations

51

OB-11.2: For Known Dichorionic Multiple Gestations

51

OB-11.3: For Known Monochorionic-Diamniotic or Monochorionic-

Monoamniotic Multiple Gestations

52

OB-12: Fetal Echocardiography (ECHO)

55

OB-12.1: Fetal Echocardiography ? Coding

56

OB-12.2: Indications for Fetal Conditions

56

OB-12.3: Indications for Maternal Conditions

57

OB-12.4: Medication or Drug Exposure

57

OB-13: Fetal MRI

59

OB-13.1: Indications for Fetal MRI

60

OB-14: Abnormal Fetal Position/ Malpresentation

62

OB-14.1: Abnormal Fetal Position or Presentation

63

OB-15: Adnexal Mass/Uterine Fibroids and Uterine Anomalies 64

OB-15.1: Adnexal Mass

65

OB-15.2: Uterine Fibroids in Pregnancy

65

OB-15.3: Uterine Anomalies in Pregnancy

66

OB-16: Alloimmunization/ Rh Isoimmunization/ Other Causes of

Fetal Anemia/ Parvo/ Hydrops

68

OB-16.1: Alloimmunization/ Rh Isoimmunization/ Other Causes of Fetal

Anemia

69

OB-16.2: Exposure to Parvovirus B-19

70

OB-16.3: Twin Anemia Polycythemia Sequence

70

OB-16.4: Fetal Hydrops Associated with Polyhydramnios

70

OB-16.5: Sustained Fetal Tachycardia

70

OB-17: Amniotic Fluid Abnormalities/ Oligohydramnios/

Polyhydramnios

72

OB-17.1: Amniotic Fluid Abnormalities

73

OB-18: Cervical Insufficiency/Current Preterm Labor

75

OB-18.1: Cervical Insufficiency

76

OB-18.2: Cerclage in Place in Current Pregnancy

76

OB-18.3: Current Preterm Labor

77

OB-19: Decreased Fetal Movement/ No Fetal Heart Tones

79

OB-19.1: No Fetal Heart Tones

80

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Obstetrical Ultrasound Imaging

OB Ultrasound Imaging Guidelines

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OB-19.2: Decreased Fetal Movement

80

OB-20: Fetal Growth Problems (FGR and Macrosomia)

81

OB-20.1: Fetal Growth Restriction Current Pregnancy

82

OB-20.2: Macrosomia ? Large for Dates Current Pregnancy

83

OB-21: Placental or Cord Abnormalities

85

OB-21.1: Single Umbilical Artery/Two Vessel Cord

86

OB-21.2: Vasa Previa

86

OB-21.3: Placental or Cord Abnormalities

87

OB-21.4: Subchorionic Hematoma or Placental Hematoma

88

OB-21.5: Suspected Abruptio Placentae

88

OB-21.6: Placenta Previa

89

OB-21.7: Placenta Accreta Spectrum/Placenta Percreta

90

OB-22: Post-term/Late-term Pregnancy

93

OB-22.1: Post-term/Late-term Pregnancy

94

OB-23: Preterm/Prelabor Rupture of Membranes

95

OB-23.1: Current Preterm Prelabor Rupture of Membranes (PPROM)96

OB-23.2: Current Prelabor Rupture of Membranes (PROM)

96

OB-24: Previous C-section or History of Uterine Scar

97

OB-24.1: Previous C-section or History of Uterine Scar

98

OB-25: Termination of Pregnancy ? Imaging

99

OB-25.1: Imaging for Planned Pregnancy Termination

100

OB-26: Trauma

101

OB-26.1: Trauma ? Imaging

102

OB-27: Unequal Fundal Size and Dates

103

OB-27.1: Unequal Fundal Size and Dates

104

OB-28: Procedure Coding Basics for Established Pregnancy 105

OB-28.1: Procedure Coding Basics for Established Pregnancy General

Considerations

106

OB-28.2: Required Elements for First Trimester OB Ultrasound 106

OB-28.3: Required Elements for Second or Third Trimester Fetal

Anatomic Evaluation OB Ultrasound

107

OB-28.4: Required Elements for a Detailed Fetal Anatomic Evaluation

OB Ultrasound

109

OB-28.5: Fetal Nuchal Translucency

111

OB-28.6: Limited and Follow-up Studies

112

OB-28.7: Obstetric Transvaginal Ultrasound

112

OB-28.8: Biophysical Profile (BPP)

113

OB-28.9: Fetal Doppler

114

OB-28.10: Duplex Scan (Uterine Artery)

115

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Obstetrical Ultrasound Imaging

OB Ultrasound Imaging Guidelines

OB-28.11: Fetal Echocardiography OB-28.12: 3D and 4D Rendering

V1.0

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Obstetrical Ultrasound Imaging

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