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Pre-Gestational Diabetes/Gestational DiabetesPatient 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?For Pre-Gestational Diabetes – Not on medication Please see number 6For Pre-Gestational Diabetes – On medication Please see number 7For Gestational Diabetes – Diet Controlled Please see number 8For Gestational Diabetes – On Medications Please see number 9 6. ? Pre-Gestational Diabetes NOT on Medication First Trimester Ultrasound - < 14 weeks? CPT? 76801 AND/OR ? CPT ?76817Gestational age at time of imaging _____________ Fetal Anatomy Scan – Optimally completed at ≥ 18 weeks, may be considered at ≥ 16 weeks ? CPT? 76811 Gestational age at time of imaging _____________ Fetal Echocardiogram – Suggested at ≥ 18 weeks gestation ? CPT? 76825 ? CPT? 76827 ? CPT? 93325Gestational age at time of imaging _____________ Growth Ultrasound – Suggested starting at 32 weeks ? CPT? 76816 Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Biophysical Profile OR Modified BPP – Typically begins at 32 weeks? CPT? 76818 OR ? CPT? 76819 OR ? CPT? 76815Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________7. ? Pre-Gestational Diabetes on Medication First Trimester Ultrasound - < 14 weeks? CPT? 76801 AND/OR ? CPT ?76817Gestational age at time of imaging _____________ Fetal Anatomy Scan – Optimally completed at ≥ 18 weeks, may be considered at ≥ 16 weeks ? CPT? 76811 Gestational age at time of imaging _____________ Fetal Echocardiogram – Suggested at ≥ 18 weeks gestation ? CPT? 76825 ? CPT? 76827 ? CPT? 93325Gestational age at time of imaging _____________ Growth Ultrasound – Suggested starting at viability, 23 weeks ? CPT? 76816 Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Biophysical Profile OR Modified BPP – Typically begins at 32 weeks (If additional risk factors present begins at 26 weeks)? CPT? 76818 OR ? CPT? 76819 OR ? CPT? 76815Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Umbilical Artery Doppler – Upon diagnosis of Fetal Growth Restriction? CPT? 76820Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________8. ? Gestational Diabetes – Diet Controlled Growth Ultrasound – Suggested once at the time of diagnosis and then starting at 32 weeks ? CPT? 76816 Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Biophysical Profile OR Modified BPP – Typically begins at 34 weeks ? CPT? 76818 OR ? CPT? 76819 OR ? CPT? 76815Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________9. ? Gestational Diabetes – On Oral Medications or Insulin Fetal Anatomy Scan – Optimally completed at ≥ 18 weeks, may be considered at ≥ 16 weeks ? CPT? 76811 Gestational age at time of imaging _____________ Fetal Echocardiogram – Suggested at ≥ 18 weeks gestation ? CPT? 76825 ? CPT? 76827 ? CPT? 93325Gestational age at time of imaging _____________ Growth Ultrasound – Suggested starting at 23 weeks ? CPT? 76816 Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Biophysical Profile OR Modified BPP – Typically begins at 32 weeks(If additional risk factors present begins at 26 weeks) ? CPT? 76818 OR ? CPT? 76819 OR ? CPT? 76815Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ Umbilical Artery Doppler – Upon diagnosis of Fetal Growth Restriction ? CPT? 76820Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________10 . 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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