EviCore



High Risk PregnancyPatient Name: DiagnosisDiagnosis, if known or rule out:ICD-10 Codes:Date of last visit:Clinical Information 1. 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. Requested Imaging Study First Trimester Imaging? CPT? 76801 AND/OR ? CPT? 76817 Gestational age at time of imaging _____________Fetal Anatomy Scan – Optimally completed at ≥ 18 weeks, may be considered at ≥ 16? CTP? 76811Gestational 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? CPT? 76818 OR ? CPT? 76819 OR ? CPT? 76815Gestational age at time of initial imaging _____________Frequency of imaging ____________Quantity ____________ High Risk Indications Maternal Age? Age greater than or equal to 35 years of age at estimated time of deliveryIllicit or recreational drug use (including cigarettes and alcohol)? Recreational drug or alcohol use during current pregnancy ? 10 or more cigarettes a day ? Other nicotine exposure (e-cigs, vaping, chewing, patch) ? Maternal history of IV drug abuse ? Current use of Suboxone, Subutex or MethadoneMaternal Disease or Health Conditions? Anemia, less than 8 grams Hgb or 24% HCT ? Asthma, poorly controlled? Autoimmune disease ? Bariatric surgery ? Connective tissue disorders ? Lupus? Rheumatoid Arthritis ? Scleroderma? Sjogren’s ? Other _________________________? DVT/PE or Maternal thrombophilia? Antiphospholipid Syndrome? Factor V Leiden mutation? Antithrombin III deficiency? Protein C/Protein S deficiency? Prothrombin gene mutation? Other ________________________ ? Genetic diseases? Cystic Fibrosis? Known carrier of Spinal Muscular Atrophy (SMA)? Tay-Sachs? Other _________________________? Heart disease (Maternal) – ? New York Heart Association class III or IV greater ? Arrhythmia? Other _________________________? Hemoglobinopathies ? Sickle cell disease ? Beta Thalassemia ? Other _________________________? History of endometrial ablation or Uterine Artery embolization ? Hyperthyroidism ? Hypothyroidism, poorly controlled ? Liver disease ? Cholestasis of pregnancy ? Hepatitis ? Other _________________________? Maternal malnutrition (BMI < 18.5) ? PKU ? Renal disease pyelonephritis, glomerulonephritis, or persistent protein in the urine renal insufficiency? Seizure disorders – on antiepileptic medication? Systemic malignancy ? Other _______________ Previous Pregnancy Related Risk Factors? History of multiple miscarriages – No known cause? 2 or more miscarriages and currently ≥ 35 years old? 3 or more miscarriages and currently < 35 years old? Prior pregnancy with SGA ? Baby weighing < 2500 grams at term ? FGR less than the 10th percentile of expected weight? Prior pregnancy with adverse outcome ? Accreta? Abruption ? Early onset preeclampsia ≤ 34 weeks? FGR at any gestational age? Nonimmune hydrops? Other ___________________? Rh sensitization/Isoimmunization in prior pregnancy. ? Other _______________Current Pregnancy Related Risk Factors? Abnormal 1st or 2nd trimester screening? MSAFP? Low PAPP_A? Abnormal cfDNA ? Known chromosomal abnormalities? Abnormal FNT ≥2.5mm? Thickened nuchal fold ≥ 5 mm at 16 to 20 weeks; ≥ 6mm at 20 to 22 weeks? Significant structural anomaly ? Fetal congenital heart disease? Sustained fetal arrhythmias ? Gastroschisis ? Fetal Ventriculomegaly ? Conception with assisted reproductive technologies (IVF) ? Grand multiparity: must have completed 5 or more pregnancies of greater than 20 weeks gestation? No prenatal care prior to 28 weeks ? Other ___________________Maternal Infections? Acquired Immune Deficiency Syndrome/HIV Positive ? Chicken Pox/Varicella? Cytomegalovirus (CMV) ? Known parvovirus in current pregnancy ? Malaria? Rubella ? Syphilis, untreated ? Toxoplasmosis ? Tuberculosis? Other ___________________ 7. 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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