Evicore OB Ultrasound Imaging V20.0.2018 Eff 05.17.18

Home , Fetal movement, Fundal height, Muscle tone

CLINICAL GUIDELINES OB Ultrasound Imaging Policy Version 20.0.2018 Effective May 17, 2018

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 2016 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.

Obstetrical Ultrasound Imaging Guidelines Abbreviations and Glossary for OB Ultrasound Imaging Guidelines 4 OB-1: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping with or without Trauma 6 OB-1.1: Abdominal Pain 7 OB-1.2: Trauma 7 OB-1.3: Vaginal Bleeding and/or Abdominal/Pelvic Cramping/Pain 7 OB-1.4: Ectopic Pregnancy 8 OB-1.5: Spontaneous Abortion 8 OB-1.6: Hydatidiform Mole 9 OB-2: Abnormal Fetal Position or Presentation 10 OB-3: Alloimmunization/Rh Isoimmunization/Other Causes of Fetal Anemia/Parvo/Hydrops 12 OB-3.1: Alloimmunization/RH Isoimmunization/Other Causes of Fetal Anemia 13 OB-3.2: Exposure to Parvovirus B-19 13 OB-3.3: Twin Anemia Polycythemia Sequence 13 OB-3.4: Fetal Hydrops Associated with Polyhydramnios 14 OB-4: Amniotic Fluid Abnormalities/ Oligohydramnios/ Polyhydramnios 16 OB-5: Fetal Anatomic Scan 19 OB-6: No Fetal Heart Tone/Decreased Fetal Movement 22 OB-7: Fetal Echocardiography (ECHO) 24 OB-8: Fetal Growth Problems 28 OB-8.1: Fetal Growth Restriction-Small for Dates Current Pregnancy 29 OB-8.2: Macrosomia-Large for Dates Current Pregnancy 30 OB-9: Placental or Cord Abnormalities 32 OB-9.1: Vasa Previa 33 OB-9.2: Placental or Cord Abnormalities 33 OB-9.3: Subchorionic Hematoma or Placental Hematoma 33 OB-9.4: Suspected Abruptio Placentae 34 OB-9.5: Placenta Previa 34 OB-9.6: Placenta Accreta/Placenta Percreta 34 OB-10: Fetal Aneuploidy and Anomaly Screening 36 OB-11: High Risk Pregnancy 41 OB-11.1: High Risk Group One-Risk Factors 43 OB-11.2: High Risk Group Two – Findings on Ultrasound That May Require Further Imaging 45 OB-11.3: High Risk Group Three – BMI 45 OB-11.4: High Risk Group Four 47 OB-11.5: High Risk Group Five: Zika Virus 47 OB-11.6: High Risk Group 6 – Pre-Gestational Diabetes on Oral Medications or Insulin 48 OB-11.7: High Risk Group Seven Gestational Diabetes 50 OB-11.8: Hypertension 52 OB-11.9: Single Umbilical Artery 53

______© 2018 eviCore healthcare. All Rights Reserved. Page 2 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 OB OB OB Mass OB OB OB OB OB OB OB OB OB OB OB OB ------24: Procedure Coding B Coding Procedure 24: Anomalies/Adnexal/Pelvic23:Uterine Masses/OvarianCysts or Dates and Size Fundal Unequal 22: 21:Uncertain Dates Imaging Trimester Third 20: Membranes of Rupture Preterm/Premature 19: Date18:Post Pregnancy 17:Previous C 16: Mu 15: Macrosmia Device(IUD)14:Intrauterine Insufficiency/Current13:Cervical LaborPreterm Infertility of History 12: 26: Imaging for Planned Pregnancy Termination Pregnancy Planned for Imaging 26: Substances and Medications Risk High 25: . All Rights Reserved. Rights All . healthcare eviCore

OB OB OB OB OB OB OB OB OB OB Ultrasound OB OB OB OB OB OB OB OB ------24.13: Fetal MRI Fetal 24.13: Rendering 4D and 3D 24.12: Echocardiography Fetal 24.11: Artery) (Uterine Scan Duplex 24.10: Doppler Fetal 24.9: (BPP) Profile Biophysical 24.8: Ultrasound Transvaginal Obstetric 24.7: Follow and Limited 24.6: Translucency Nuchal Fetal 24.5: Ultrasound OB Evaluation Anatomic Fetal aDetailed for Elements Required 24.4: OB Evaluation Anatomic Fetal Trimester Third or Second for Elements Required 24.3: Ultrasound OB Trimester First for Elements Required 24.2: Selection Code Ultrasound OB 24.1: Labor Preterm Current 13.3: pregnancy in current place in Cerclage 13.2: Insufficiency Cervical 13.1: Stillbirth of History 11.11: Pre of History 11.10: ltiple Pregnancies ltiple

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

Abbreviations and Glossary for OB Ultrasound Imaging Guidelines ACOG American College of Obstetricians and Gynecologists AFI amniotic fluid index AFP alpha-fetoprotein CST contraction stress test B-mode a two dimensional imaging procedure, B-mode ultrasound is the basis for (brightness) all static and real time B-scan images BPP Biophysical Profile includes the ultrasound variables: fetal breathing, muscle tone, and movement as well as amniotic fluid volume. BPP may be performed with or without a non-stress test (NST) which involves fetal heart rate (FHR) monitoring. D & C/D & E dilatation and curettage/ Dilation and Evacuation dichorionic twins having distinct chorions (membrane that forms the fetal part of the twins placenta), including monozygotic twins (from one oocyte [egg]) separated within 72 hours of fertilization and all dizygotic twins (from two oocytes fertilized at the same time Doppler involves measuring a change in frequency when the motion of vascular flow is measured EDC Estimated Date of Confinement; determined from the first day of the last menstrual cycle FHR fetal heart rate hCG human chorionic gonadotropin IDDM insulin-dependent diabetes mellitus FGR Fetal growth restriction; an estimated or actual weight of the fetus below 10th percentile for gestational age M-mode an ultrasound imaging technique in which structure movement can be depicted in a wave-like manner; primarily used in cardiac and fetal cardiac imaging macrosomia estimated fetal weight of greater than 4000 or 4500 grams monochorionic twins developed from one oocyte (egg) developing with a single chorions twins (membrane that forms the fetal part of the placenta) NICU Neonatal Intensive Care Unit NST fetal non-stress test oligohydramnios diminished amniotic fluid volume (AFV) for gestational age; definitions include: 1.) maximum deepest pocket of ≤ 2cm, and, 2.) AFI of ≤ 5cm or < the 5th percentile for gestational age PACS Picture Archiving and Communications System polyhydramnios 1.) AFI ≥ 24cm, or maximum vertical pocket of ≥ 8 cm PROM preterm rupture of membranes quad screen alpha-fetoprotein (AFP), estriol, human chorionic gonadotropin (hCG), inhibin A real time scan considered the most common type of ultrasound; a 2-dimensional scan that reflects structure and motion over time, scanning and display of images are run at a sufficiently rapid rate so that moving structures can be viewed moving at their natural rate; frame rates ≥ 15 frames per second are considered “real time”

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Obstetrical Ultrasound Imaging General Guidelines Required Documentation  An evaluation of pregnancy with history and physical exam (an initial office visit) is necessary prior to obstetric ultrasound imaging requests  The following information must be submitted with each request:  Anticipated date of service  Expected date of delivery  Gestational age at date of service  Results of prior ultrasound studies if available

Inappropriate Use of OB Ultrasound  Obstetrical ultrasound studies cannot be authorized for payment for individuals who do not have a positive pregnancy test or clinical evidence of a pregnancy (fetal heart tones)  Obstetrical ultrasound is not appropriate for the following:  Sex determination only.  To provide a keepsake or souvenir picture.

Practice Note In the absence of other specific indications, the optimal time for a single ultrasound examination is at 18 to 22 weeks of gestation. This timing allows for a survey of fetal anatomy in most women and an accurate estimation of gestational age.2

References 1. Reddy UM, Abuhamad AZ, Levine D, et al. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society of Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol Survey. 2014;69(8):453-455. Accessed November 3, 2017. http://journals.lww.com/obgynsurvey/Abstract/2014/08000/Fetal_Imaging___Executive_Summary_of_ a_Joint.4.aspx. 2. Practice Bulletin No. 175 Summary: Ultrasound in pregnancy. Obstet Gynecol. 2016;128(6):1459- 1460. Accessed November 3, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ Ultrasound_in.50.aspx.

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OB-1: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping with or without Trauma OB-1.1: Abdominal Pain 7 OB-1.2: Trauma 7 OB-1.3: Vaginal Bleeding and/or Abdominal/Pelvic Cramping/Pain 7 OB-1.4: Ectopic Pregnancy 8 OB-1.5: Spontaneous Abortion 8 OB-1.6: Hydatidiform Mole 9

OB-1.1: Abdominal Pain

For abdominal pain or trauma that presents without bleeding:  Initially CPT® 76815 and/or CPT® 76817 for limited ultrasound when medically indicated or  CPT® 76801 and/or CPT® 76817 when complete ultrasound has not yet been performed, if less than 14 weeks or  CPT® 76805 (plus CPT® 76810 if more than one fetus) if equal to or greater than 14 weeks, when complete fetal anatomic scan CPT® 76805 is planned and has not yet been performed.

OB-1.2: Trauma

Blunt trauma in the first trimester (prior to 13 weeks) generally does not cause pregnancy loss with the exception of profound hypotension: No imaging is indicated unless there is cramping and/or bleeding. Management of outpatient trauma implies that the trauma was not serious enough to be treated as inpatient. The major risk is abruptio placentae:  Monitor for uterine contractions for those > 20 weeks.  CPT® 76805 (plus CPT® 76810 if more than one fetus) when complete fetal anatomic scan CPT® 76805 is planned and has not yet been performed, or  CPT® 76815 or CPT® 76816 (if a complete anatomy ultrasound was done previously)  Additionally, if greater than 24 weeks, BPP CPT® 76818 or CPT® 76819 or CPT® 76815 for AFI can be considered.  Other advanced imaging may be indicated, send for Medical Director review.

OB-1.3: Vaginal Bleeding and/or Abdominal/Pelvic Cramping/Pain Vaginal Bleeding and/or Abdominal/Pelvic Cramping/Pain First Trimester  Initially CPT® 76815 and/or CPT® 76817 for limited ultrasound when medically indicated or  CPT® 76801 when complete ultrasound has not yet been performed, if less than 14 weeks and/or CPT® 76817 may be performed once when medically indicated for complete ultrasound. Second and Third Trimesters CPT® 76815 or CPT® 76816 if a complete anatomic ultrasound was done previously and/or CPT® 76817

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OB-1.4: Ectopic Pregnancy Ectopic Pregnancy First Trimester Signs and symptoms of ectopic pregnancy include pain and/or bleeding Initially CPT® 76815 and/or CPT® 76817 for limited ultrasound when medically indicated or CPT® 76801 when complete ultrasound has not yet been performed, if less than 14 weeks and/or CPT® 76817 may be performed once when medically indicated for complete ultrasound. If patient has a history of ectopic pregnancy with non-doubling hCG without pain and bleeding, ultrasound can be performed (CPT® 76801 and/or CPT® 76817) to confirm an intrauterine pregnancy If ectopic pregnancy is being treated non-surgically with Methotrexate, imaging may be required per OB-1: Vaginal Bleeding and/or Abdominal/Pelvic Pain/Cramping with or without Trauma or the imaging guidelines above for ectopic pregnancy.

OB-1.5: Spontaneous Abortion Spontaneous Abortion  For spontaneous abortion (miscarriage), ultrasound can be performed to evaluate threatened or missed abortion (with or without vaginal bleeding prior to 20 weeks)  Initially CPT® 76815 and/or CPT® 76817 for limited ultrasound when medically indicated or  CPT® 76801 when complete ultrasound has not yet been performed, if less than 14 weeks and/or CPT® 76817 may be performed once when medically indicated for complete ultrasound  Repeat ultrasound (CPT® 76815 or CPT® 76816 if a complete anatomic ultrasound was done previously and/or CPT® 76817) is appropriate in the setting of rising or non-falling serum hCG levels at weekly intervals  Ultrasound imaging can be repeated earlier than seven days if there are new symptoms  For complete spontaneous abortion, ultrasound is generally not indicated if there is no pain, no ongoing bleeding, and hCG levels are decreasing

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OB-1.6: Hydatidiform Mole Hydatidiform Mole First, Second and Third Trimester  Ultrasound can be performed for diagnosis of hydatidiform mole  Initially CPT® 76815 and/or CPT® 76817 for limited ultrasound when medically indicated or  CPT® 76801, when complete ultrasound has not yet been performed, if less than 14 weeks, and/or CPT® 76817 may be performed once when medically indicated for complete ultrasound.  Following treatment with D & C and/or Methotrexate, serial serum hCG values are measured until they become negative.  Ultrasound may be necessary for follow-up (CPT® 76815, or CPT® 76816 if a complete anatomic ultrasound was done previously, and/or CPT® 76817) if hCG titers are not decreasing as expected, are increasing following treatment, or if there is onset of pain despite falling hCG titers.

References 1. Committee Opinion No. 529: Placenta accreta. Obstet Gynecol. 2012;120(1):207-211, reaffirmed 2017. Accessed November 3, 2017. http://journals.lww.com/greenjournal/Citation/2012/07000/Committee_Opinion_No__529___Placenta _Accreta.42.aspx.

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OB-2: Abnormal Fetal Position or Presentation OB-2.1: Abnormal Fetal Position or Presentation 11

______© 2018 eviCore healthcare. All Rights Reserved. Page 10 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Reference should beconfirmed by anultrasound assessment. isnot always accurate andmaybeuncomfortable. Suspected fetal malpresentation presentation by abdominal palpation should not be offered before 36 weeks because it when presentation is likely to influence the plans for the birth. Routine Fetal presentation should be assessed by abdominal palpation at 36 weeks or later, Practice Note  Notes Coding  or Presentation Position Fetal Abnormal OB-2.1: Guidelines Imaging 8 © 201     2016 Pract xternal.44.aspx http://journals.lww.com/greenjournal/Abstract/2016/02000/Practice_Bulletin_No__161_Summary___E Reportonethe of following: breech presentation): of Confirmation

. All Rights Reserved. Rights All . healthcare eviCore has not yet been performed or CPT anatomic scan when complete fetal anatomic scan CPT CPT gestation unless deliveryisimminent Ultrasoundto determine fetalposition fetal position to allow for external cephalic version An ultrasound can be performed at 36 weeks gestation or greater to determine - ;127(2):412 Obstetrics & Gynecology Obstetrics version. cephalic External Summary. 161: No. Bulletin ice

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-3: Alloimmunization/Rh Isoimmunization/Other Causes of Fetal Anemia/Parvo/Hydrops OB-3.1: Alloimmunization/RH Isoimmunization/Other Causes of Fetal Anemia 13 OB-3.2: Exposure to Parvovirus B-19 13 OB-3.3: Twin Anemia Polycythemia Sequence 13 OB-3.4: Fetal Hydrops Associated with Polyhydramnios 14

Fetal anemia and hydrops may be a result of immune conditions, such as red-cell or Kell alloimmunization, non-immune hydrops caused by parvovirus B19 infection or any other known acquired or congenital causes of fetal anemia.

OB-3.1: Alloimmunization/RH Isoimmunization/Other Causes of Fetal Anemia Imaging for Alloimmunization/ RH Isoimmunization:  Ultrasound (CPT® 76816) every 2 to 4 weeks to assess fetal growth starting after performance of the fetal anatomic scan CPT® 76811 at 16 weeks or greater. If less than 16 weeks, send to MD Review  Weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST starting at 32 weeks or sooner depending on fetal condition  3a. Weekly fetal middle cerebral artery MCA Doppler (CPT® 76821) starting at 20 weeks or sooner depending on fetal condition when any one of the following maternal antibody titers are ≥ 1:8  Anti-D antibody and/or  Anti-Duffy (.i.e anti-fya, anti-fyb) antibody and/or  Anti-Kidd antibody  3b. With Anti-Kell antibody (any antibody titer) MCA Doppler (CPT® 76821) once weekly  3c. Evidence of fetal hydrops on previous imaging once weekly MCA Doppler (CPT® 76821)  Because MCA-PSV increases across gestation, results should be adjusted for gestational age. Measurements can be initiated as early as 16 weeks of gestation if there is a past history of early severe fetal anemia or very high titers. The optimal interval between examinations has not been determined, but should be one to two weeks based on clinical experience and what is known about progression of fetal anemia in this setting

OB-3.2: Exposure to Parvovirus B-19  Parvovirus B-19 (Fifth Disease):  Ultrasound (CPT® 76816) every 2 to 4 weeks to assess fetal growth starting at time of known exposure and continuing for 8 to 10 weeks post-exposure  Weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST starting at time of known exposure if ≥ 24 weeks gestation and continuing for 8 to 12 weeks post-exposure  Fetal middle cerebral artery (MCA) Doppler (CPT® 76821) every 1 to 2 weeks, starting at time of known exposure, if 16 weeks or greater and continuing for 8 to 12 weeks post-exposure

OB-3.3: Twin Anemia Polycythemia Sequence  See: OB-16.3: Monochorionic-diamniotic or monochorionic-monoamniotic multiple pregnancies

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OB-3.4: Fetal Hydrops Associated with Polyhydramnios  Fetal hydrops associated with Polyhydramnios: if diagnosed with hydrops, image according to OB-3.1: Alloimmunization/Rh Isoimmunization/Other Causes of Fetal Anemia

Practice Notes Rhesus isoimmunization/alloimmunization is the process through which fetal Rh+ red blood cells enter the circulation of an Rh negative mother causing her to produce antibodies which can cross the placenta and destroy the red blood cells of the current Rh+ fetus in subsequent Rh+ pregnancies.

Twin anemia polycythemia sequence (TAPS) may occur spontaneously in up to 5% of monochorionic twins and may also develop after incomplete laser treatment in twin-twin transfusion syndrome (TTTS) cases. As with TTTS the underlying mechanism is thought to be abnormal placental vascular anastomoses. One twin develops anemia and the other polycythemia. One of the features suggesting towards the diagnosis is discordance in fetal middle cerebral artery peak systolic velocity (MCA-PSV) measurements

Peak systolic velocity (PSV) of the fetal middle cerebral artery can be used as a substitute for amniocentesis to evaluate a fetus at risk for anemia due to Rhesus isoimmunization/alloimmunization

References 1. Mari G, Deter RL, Carpenter RL, et al. Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization. Collaborative Group for Doppler Assessment of the Blood Velocity in Anemic Fetuses. N Engl J Med. 2000;342(1):9-14. Accessed November 14, 2017. http://www.nejm.org/doi/full/10.1056/NEJM200001063420102. 2. Lopriore E, Slaghekke F, Oepkes D, et al. Clinical outcome in neonates with twin anemia- polycythemia sequence. Am. J. Obstet. Gynecol. 2010; 203(1):54.e1-5. Accessed November 14, 2017. http://www.ajog.org/article/S0002-9378(10)00245-0/fulltext?cc=y=. 3. Slaghekke F, Kist WJ, Oepkes D, et al. Twin anemia-polycythemia sequence: diagnostic criteria, classification, perinatal management and outcome. Fetal Diagn Ther. 2010;27(4):181-90. Accessed November 20, 2017. https://www.ncbi.nlm.nih.gov/pubmed/20339296. 4. Suzuki S. Twin anemia-polycythemia sequence with placental arterio-arterial anastomoses. Placenta. 2010;31(7):652. Accessed November 14, 2017. http://www.placentajournal.org/article/S0143- 4004(10)00158-X/pdf. 5. Gucciardo L, Lewi L, Vaast P, et al. Twin anemia polycythemia sequence from a prenatal perspective. Prenat Diagn 2010;30(5):438-42. Accessed November 14, 2017. http://onlinelibrary.wiley.com/doi/10.1002/pd.2491/epdf. 6. Weingertner AS, Kohler A, Kohler M, et-al. Clinical and placental characteristics in four new cases of twin anemia-polycythemia sequence. Ultrasound Obstet Gynecol. 2010;35(4):490-4. Accessed November 14, 2017. http://onlinelibrary.wiley.com/doi/10.1002/uog.7508/abstract 7. Practice Bulletin No. 75: Management of alloimmunization , reaffirmed 2016 Obstet Gynecol. 2006 Aug;108(2):457-464. Accessed November 14, 2017. https://www.researchgate.net/publication/289994990_ACOG_Practice_Bulletin_No_75_Management _of_Alloimmunization

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8. Lamont RF, Sobel JD, Vaisbuch E, et al. Parvovirus B19 infection in human pregnancy .Brit J Obstet Gynceol. 2011;118:175-186. Accessed November 14, 2017. http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02749.x/abstract. 9. Reddy UM, Filly RA, and Copel JA. Prenatal imaging: ultrasonography and magnetic resonance imaging. Obstet Gynecol. 2008;112(1):145-157. Accessed November 14, 2017. http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2008&issue=07000&article=0002 4&type=abstract 10. Reddy UM, Abuhamad AZ, Levine D et al. Fetal Imaging: executive summary of a joint Eunice Kennedy Shriver National Institute Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society of Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol Survey. 2014;69(8):453-455. Accessed November 14, 2017. http://journals.lww.com/obgynsurvey/Abstract/2014/08000/Fetal_Imaging___Executive_Summary_of_ a_Joint.4.aspx 11. Mari G, Norton ME, Stone J, et al. Society for Maternal-Fetal Medicine (SMFM) Clinical guideline No. 8: The fetus at risk for anemia: diagnosis and management. Am J Obstet Gynecol. 2015:212(6):697- 710. Accessed November 14, 2017. http://www.ajog.org/article/S0002-9378(15)00203-3/pdf. 12. Crane J, Mundle W, and Boucoiran I. SOGC Clinical Practice Guideline No. 316. Parvovirus B19 Infection in Pregnancy. J Obstet and Gynecol Canada. 2014;36(12):1107-1116. Accessed January 29, 2018. http://www.jogc.com/article/S1701-2163(15)30390-X/fulltext. 13. Practice Bulletin No. 151. Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstet Gynecol. 2015 Jun;125(6):1510-1525. Accessed January 29, 2018. https://journals.lww.com/greenjournal/Citation/2015/06000/Practice_Bulletin_No__151___Cytomegal ovirus,.54.aspx 14. Khalil A, Rodgers M, Baschat A et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancies. Ultrasound Obstet Gynecol 2016;47(2):247–263. Accessed November 16, 2017. http://onlinelibrary.wiley.com/doi/10.1002/uog.15821/epdf

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OB-4: Amniotic Fluid Abnormalities/ Oligohydramnios/ Polyhydramnios OB-4.1: Amniotic Fluid Abnormalities 17

OB-4.1: Amniotic Fluid Abnormalities

For suspected polyhydramnios or oligohydramnios:  One ultrasound is appropriate  CPT® 76805 (plus CPT® 76810 if more than one fetus) for complete fetal anatomic scan when complete fetal anatomic scan CPT® 76805 is planned and has not yet been performed or  If complete fetal anatomic scan CPT® 76805was previously performed:  CPT® 76815 for limited ultrasound or  CPT® 76816 for complete ultrasound (if complete anatomy ultrasound was done previously For confirmed diagnosis of polyhydramnios: AFI ≥ 24cm or maximum deepest vertical pocket ≥ 8cm.  One ultrasound (CPT® 76816)  Starting at ≥ 22 weeks, every 3 to 4 weeks for mild polyhydramnios; AFI ≥ 24 cm to 30 cm or maximum deepest vertical pocket ≥ 8 cm to 10 cm  Starting at ≥ 22 weeks, every 2 weeks for severe polyhydramnios; AFI > 30 or maximum deepest vertical pocket is > 10 cm  Starting at 26 weeks, weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST, if maximum vertical pocket is ≥ 8 cm or if AFI ≥ 24 cm.  Starting at 26 weeks, twice-weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST, if maximum deepest vertical pocket is > 10 cm or an AFI > 30  One time fetal echo if initial echo has not already been performed (CPT® 76825 and/or CPT® 76827and/or CPT® 93325. All requests for follow-up echo go to Medical Director review. For confirmed diagnosis of oligohydramnios: AFI ≤ 5 cm or maximum vertical pocket ≤ 2 cm Starting at ≥ 22 weeks , one ultrasound (CPT® 76816) every 2 to 4 weeks for fetal growth Starting at 26 weeks, weekly biophysical profile (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST, if maximum vertical pocket ≤ 2 cm or AFI ≤ 5 cm. If less than 26 weeks send to Medical director review Starting at time of diagnosis, weekly umbilical artery Doppler ( CPT® 76820)

Practice Notes Polyhydramnios refers to excessive amniotic fluid volume. It is determined with AFI ≥ 24 cm or (greater than the 95th percentile by gestational age), or maximum deepest vertical pocket ≥ 8 cm. Oligohydramnios refers to diminished amniotic fluid volume. At 30 weeks or greater, it is determined with AFI ≤5 cm by measuring fluid in each of the four quadrants or by the maximum single deepest vertical pocket ≤ 2 cm (is the best definition of oligohydramnios). At less than 30 weeks, oligohydramnios is determined by a gestation age cut off of ≤ 5 percentile Polyhydramnios can be an early presenting finding of fetal hydrops associated with fetal anemia. Middle cerebral artery Doppler is commonly used to diagnose whether this fetal anemia is present or not. See: OB-3.1: Alloimmunization/RH Isoimmunization/Other Causes of Fetal Anemia.

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Polyhydramnios may also present as a finding of cardiac dysfunction, fetal arrhythmias or cardiac malformation. Fetal echocardiography is commonly performed to determine if any other conditions are present or not. See: OB-7: Fetal Echocardiography (ECHO)

References 1. Practice Bulletin No. 175: Ultrasound and pregnancy. Obstet Gynecol. 2016;128(6):1459-1460. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ Ultrasound_in.50.aspx. 2. Practice Bulletin 145: Antepartum fetal surveillance. Obstet Gynecol. 2014;124(1):182-192, reaffirmed 2016. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Citation/2014/07000/Practice_Bulletin_No__145___Antepartum_ Fetal.35.aspx.

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OB-5: Fetal Anatomic Scan OB-5.1: Initial Screening for Fetal Anomalies 20 OB-5.2: Follow-Up 20

OB-5.1: Initial Screening for Fetal Anomalies  A fetal anatomic scan to screen for anomalies is ideally performed at 18 to 20 weeks, but may be performed after week ≥ 16. If less than 16 weeks gestation, send to MD review  CPT® 76817 transvaginal ultrasound can be considered if the cervical length is less than or equal to 3.0 cm with transabdominal ultrasound measurement  Reported as CPT® 76805 if the patient is not high risk.  If pregnancy is high risk report as (CPT® 76811). A detailed fetal anatomic scan (CPT® 76811) is performed by a Maternal Fetal Medicine (MFM) specialist, Perinatologist, Radiologist, or AIUM or ACR accredited facilities as the screening anatomic study. See: OB-11: High Risk Pregnancy

OB-5.2: Follow-Up  Follow-up ultrasounds (CPT® 76816) can be performed every 3 to 6 weeks to evaluate fetal growth if pregnancy is high risk. See also: OB-11: High Risk Pregnancy  Follow-up ultrasound (CPT® 76815 or CPT® 76816 can be performed if indeterminate, incomplete or equivocal finding on initial fetal anatomic scan. A limited ultrasound CPT® 76815 if limited to a follow up of a single item  Detailed anatomy ultrasound CPT® 76811 can be performed if not previously performed when initial fetal anatomic scan CPT® 76805 is abnormal. See: OB-11: High Risk Pregnancy

Coding Notes

Fetal Anatomic Scan - Coding Notes A complete transabdominal ultrasound (CPT® 76805). See: OB-24.3: Required Elements for Second or Third Trimester Fetal Anatomic CPT® 76805 Evaluation OB Ultrasound CPT® 76810 is an add-on code used with the primary procedure CPT®76810 CPT® 76810 to report each additional fetus if there is a multiple gestation CPT® 76805 and CPT® 76810 should only be reported once per pregnancy CPT® 76805 unless the mother changes to a new medical caregiver at a new office, and CPT® 76810 there is a medical indication for ultrasound CPT® 76811 and CPT® 76812 are defined as including all of the requirements listed for procedures CPT® 76805 and CPT® 76810 plus additional detailed anatomic examination. The pregnancy must also be high CPT® 76811 risk to support CPT® 76811 and CPT® 76812. In addition the report must CPT® 76812 include the detailed elements found in OB 24.4. See: OB-24.4: Required Elements for a Detailed Fetal Anatomic Evaluation OB Ultrasound CPT® 76812 is an add-on code used with the primary procedure CPT®76812 CPT® 76812 to report each additional fetus in a multiple gestation The reporting of CPT® 76811 only once per pregnancy, per practice (per CPT® 76811 NPI) is appropriate

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References 1. Wax J, Minkoff H, Johnson A, et al. Consensus report on the detailed fetal anatomic ultrasound examination: indications, components, and qualifications. J Ultrasound in Medicine. 2014 Feb;33(2):189-195. Accessed December 12, 2017. http://onlinelibrary.wiley.com/doi/10.7863/ultra.33.2.189/full. 2. Practice Bulletin No. 175: Ultrasound in pregnancy. Obstet Gynecol. 2016;128(6):1459-1460. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ Ultrasound_in.50.aspx. 3. Wax J, Minkoff H, Johnson A et al. Consensus report on the detailed fetal anatomic ultrasound examination indications, components, and qualifications. J Ultrasound Med. 2014;33(2):189-195. Accessed November 15, 2017. http://api.ning.com/files/cZ399qCqOaHeuZzVLVyhlBxiUetrbLyKO3Bw9Tt6vH2VZjNDiuNoRV*TfNUrq T5k4qdLfS6J8OlAGmAHfkKiXIDZdpW4U1-u/consensus768112014.pdf 4. Berghella V, Blackwell S, Anderson B, et al. Progesterone and preterm birth prevention: translating clinical trials data into clinical practice. Am J Obstet Gynecol. 2012;206(5):376-386. Accessed November 15, 2017. http://www.ajog.org/article/S0002-9378(12)00291-8/fulltext. 5. American Medical Association. CPT—Current Procedural Terminology. Accessed November 15, 2017. https://www.ama-assn.org/practice-management/cpt-current-procedural-terminology. 6. Practice bulletin 130: Prediction and prevention of pre-term birth. Obstet Gynecol. 2012;120(4):964- 973, reaffirmed 2016. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Citation/2012/10000/Practice_Bulletin_No__130___Prediction_a nd.42.aspx. 7. Cho, H.J. and Roh, H.J.Correlation Between Cervical Lengths Measured by Transabdominal and Transvaginal Sonography for Predicting Preterm Birth. J Ultrasound Med. 2016; 35:537–544. Accessed November 15, 2017. http://onlinelibrary.wiley.com/doi/10.7863/ultra.15.03026/epdf. 8. McIntosh J, Feltovich H, Berghella V et al. The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016; 215(3):B2-B7. Accessed November 15, 2017. http://www.ajog.org/article/S0002-9378(16)30112-0/fulltext. 9. Khalifeh A, Berghella V, Stamilio D, et al. Ultrasound approach for cervical length screening in preterm birth prevention. Am J Obstetr Gynecol. 2016 Dec;215(6):739-744. 10. Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths and quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous omen JAMA 2017 Mar 14;317(10):1047-1056. Accessed January 29, 2018. https://jamanetwork.com/journals/jama/fullarticle/2610337. 11. Jain S, Kilgore M, Edwards, RK, et al. Revisiting the cost-effectiveness of universal cervical length screening: importance of progesterone efficacy. Am J Obstet Gynecol. 2016 Jul;215(1):101.e1-7. Accessed January 29, 2018. http://www.ajog.org/article/Sooo2-9378(16)00215-5/fulltext.

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OB-6: No Fetal Heart Tone/Decreased Fetal Movement OB-6.1: No Fetal Heart Tone/Decreased Fetal Movement 23

OB-6.1: No Fetal Heart Tone/Decreased Fetal Movement  Ultrasound is appropriate to confirm suspected fetal demise The following is supported during the first trimester:  Prior to considering ultrasound for absence of fetal heart tone at less than 12 weeks, fetal heart tone assessment should be repeated at 12 weeks gestation  Ultrasound imaging is supported, prior to 12 weeks gestation, in the setting of absent fetal heart tones accompanied by other maternal signs or symptoms (such as cramping, vaginal bleeding, etc.). Report one of the following:  CPT® 76801 (plus CPT® 76802 if more than one fetus) and/or CPT® 76817 if a complete ultrasound has not yet been performed; or  CPT® 76815 for limited ultrasound and/or CPT® 76817  Note: CPT® 76816 can only be used after CPT® 76805 has been performed, therefore should not be done in the first trimester The following is supported during the second and third trimester:  If less than 24 weeks gestation, report one of the following:  CPT® 76805 if a complete fetal anatomic scan is planned and has not yet been performed during this pregnancy (plus CPT® 76810 if more than one fetus); or  CPT® 76816 if a complete ultrasound was done previously; or  CPT® 76815 for limited ultrasound; and/or  CPT® 76817 for a transvaginal ultrasound  If pregnancy is greater than or equal to 24 weeks, initial evaluation is usually done by fetal non-stress test (CPT® 59025) with: 1) AFI (CPT® 76815); or ultrasound (CPT® 76815) to document fetal heart activity or BPP (CPT® 76818 or CPT® 76819) if 24 weeks or greater; or 3) contraction stress test (CST) and AFI. No imaging is necessary if:  NST is reactive and AFI is normal or  CST is negative  If NST is non- reactive or CST is positive:  CPT® 76805 if a complete fetal anatomic scan is planned and has not yet been performed during this pregnancy (plus CPT® 76810 if more than one fetus) or  CPT® 76816 if a complete ultrasound was done previously or  CPT® 76815 for limited ultrasound

Reference 1. Practice Bulletin 145: Antepartum fetal surveillance. Obstet Gynecol. 2014;124(1):182-192, reaffirmed in 2016. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Citation/2014/07000/Practice_Bulletin_No__145___Antepartum_ Fetal.35.aspx.

______Obstetrical Ultrasound Imaging Guidelines © 2018 eviCore healthcare. All Rights Reserved. Page 23 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201 OB OB - - 7.2: Indications for Maternal Conditions Maternal for Indications 7.2: Conditions Fetal for Indications 7.1: . All Rights Reserved. Rights All . healthcare eviCore OB - 7: Fetal Echocardiography (ECHO Echocardiography Fetal 7:

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Conditions Fetal for Indications OB-7.1: identification during astandard ultrasound procedure, is not separately reimbursable. The Guidelines Imaging 8 © 201                  

Exposure of fetus to: IVF pregnancies Monochorionic twins/TTTS Anemia Fetal hydrops (See: intraabdominal venous anomaly (persistent right Single umbilical artery (two vessel cord), abnormality umbilical of cord, placenta or suspected chromosomal abnormality. Known fetal chromosomal abnormalities (fetal aneuploidy) or ultrasound findings of earlier if anomaly suspected is onprior ultrasound) ascreeningAs study typically performed at (maternal, paternal, or sibling) Congenital heart disease (CHD) or cardiac anomaly a1 in (See: Knownextra fetal cardiac structure and function If fetal structural cardiac disease suspected,is fetal echo can beperformed to evaluate fetal Suspected or known fetal arrhythmia (to define the rhythm and its importance) approved for preparation delivery of If aheart abnormality found, is afetal  Abnormal or suspected abnormal fetal cardiac evaluation on fetal anatomic scan. Transabdominal fetal echo usually is not performed prior to 16weeks separately for the following conditions: Doppler color flow echo must go to MD review) a Doppler echocardiography(Initial study to review) must MD go echo Fetal echocardiography(Initial study            minimal use of color Doppler alone, when performed for anatomical structure if maternalif non

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______       Notes Coding Conditions Maternal for Indications OB-7.2: Guidelines Imaging 8 © 201  Seizure disorder offamily history Marfan syndrome or Noonan syndrome) aFamily of history degree first relative to withthe fetus heart acongenital (such asdefect CMV,parvovirus, Coxsackie virus, Toxoplasmosis) of otherPresence maternal associated as conditions withch anomalies cardiac (su Phenylketonuria vascular diseasesCollagen (RA, Sjogren’s Scleroderma, Syndrome) Rubella infection lupus erythematosus withSystemic Anti All except diabetes gestational diabetes mellitus onnot medication unless HbA1C is > 7% Conditions: Maternal For  study) will beforwarded to Medical Director for review. Requests follow for mapping) CPT using the following CPT pregnancy, and the clinical criteria are met, then the Fetal Echo may beapproved FetalIf a Ec Follow Follow CPT Requests for Polyhydramnios        Abnormal Fetal Nuchal Translucency scan (

. All Rights Reserved. Rights All . healthcare eviCore Otherwise, perform CPT Other teratogen exposure to the fetus with a known association cardiacfor anomalies Cocaine to another specialist (MFM, Perinatologist or Radiologist) asecond for opinion. Can alsoCan perform CPT NSAIDS (Ibuprofen, Indomethacin) 2ndand 3rd trimester Vitamin greaterA than 10,000 units per day Opiates Benzodiazepines ® ®

76825 and/orCPT 76825 andCPT - - up Doppler fetal echocardiograms are reported as CPT up echocardiograms are reported as CPT

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______4. 3. 2. Donofrio 1. References pregnancy. during the 26th through the 30th week, and it rarely develops after 30 weeks o block in seven days during this high- period from 18 to 24 weeks gestation. Normal sinus rhythm can progress to complete should bestrongly considered. The most vulnerable period for the fetus is during 18th through the 26th week of pregnancy and then every other week until 32 weeks heart block, but performingweekly pulsedDoppler fetal echocardiographythefrom There are no formal guidelines for the type or the frequency of testing to detect fetal Practice Note Guidelines Imaging 8 © 201 https://www.medscape.com/medline/abstract/24763516 Circulation. Association. Heart American the from statement ascientific disease: r - https://academic.oup.com/rheumatology/article Rheumatology - http://www.pcssa.org/test/wp http://onlinelibrary.wiley.com/doi/10.1002/pd.2281/epdf and SA, Ottenkamp, Clur SSA of in children block heart congenital of Prevention A. Brucato outcome. and presentations clinical duct: arterial the of closure foetal Premature al. et L, Catte De SC, Brown M, Gewillig eview. eview. . All Rights Reserved. Rights All . healthcare eviCore - 2009;29(8):739 . Diagn Prenat MT, Moon- MT,

- 2014;129(21):2183 - 2008;47(3):iii35 .

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-8: Fetal Growth Problems OB-8.1: Fetal Growth Restriction-Small for dates Current Pregnancy 29 OB-8.2: Macrosomia-Large for Dates Current Pregnancy 30

OB-8.1: Fetal Growth Restriction-Small for Dates Current Pregnancy The ACOG definition of Fetal Growth Restriction (FGR): Estimated or actual weight of the fetus < 10th percentile for gestational age. “Abdominal Circumference < 10th percentile” also defines FGR.

For Suspected FGR: One ultrasound can be performed if there is more than a 3 week difference in fundal height and gestational age report one of the following:  CPT® 76805 (plus CPT® 76810 if more than one fetus) if a complete ultrasound has not yet been performed during this pregnancy or  CPT® 76816 if a complete ultrasound was performed previously. In order to evaluate fetal growth and confirm the diagnosis of FGR following the initial ultrasound, one follow-up ultrasound (CPT® 76816) can be performed 2 to 4 weeks following the initial ultrasound For clinical situations that have a higher probability of FGR such as maternal hypertension, maternal diabetes, previous stillbirth, etc. See: OB-11: High Risk Pregnancy, or the specific guidelines for these clinical entities for guidance regarding follow-up ultrasounds to assess fetal growth For Known FGR: ®

Ultrasound (CPT 76816) every 2 to 4 weeks to assess fetal growth starting at 22 to 24 weeks Starting at 22 to 24 weeks, weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST Starting at 22 to 24 weeks, weekly umbilical artery Doppler (CPT® 76820); if umbilical artery dopplers are abnormal, daily BPPs (CPT® 76818 or CPT® 76819) may be considered MCA Doppler (CPT® 76821) start at 34 weeks, weekly if the doppler CPT® 76820 is normal. Obstetrical Ultrasound Imaging Guidelines

OB-8.2: Macrosomia-Large for Dates Current Pregnancy The ACOG definition of macrosomia: Estimated fetal weight of greater than 4000 grams (DM) or 4500 grams (non-DM); ≥ 90th percentile or greater for gestational age.

See also: OB-11.4.a: Prior Pregnancy with Macrosomia

For Suspected Macrosomia: In a low risk pregnancy, ultrasound is generally not indicated to estimate fetal weight before 30 weeks gestation At 30 weeks gestation or greater, if there is more than a 3 week difference in fundal height and gestational age, one ultrasound can be performed to evaluate for macrosomia if clinically indicated report one of the following: TCP ® 76805 [plus CPT® 76810 if more than one fetus] if a complete fetal anatomic scan is planned and has not yet been performed or T CP ® 76816 if a complete ultrasound was done previously (See also: OB-22: Unequal Fundal Size and Dates) For Known Macrosomia ≥ 90th percentile Repeat imaging is generally not necessary unless needed to plan for delivery or if there are other high risk indications. At > 30 weeks gestation, (CPT®76816) every 2 to 4 weeks only if

other high risk indication(s) are present. Imaging recommendations are usually guided by the cause of the fetal macrosomia (obesity, DM, etc. See appropriate GL for indication) If no other high risk indication present, one CPT® 76816 at 37 weeks to plan for delivery.

References 1. Practice Bulletin No. 134: Fetal Growth Restriction. Obstet Gynecol. 2013, reaffirmed 2015;121(5):1122-1133. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2013/05000/Practice_Bulletin_No__134___Fetal_Growt h.45.aspx. 2. Practice Bulletin No. 173: Fetal Macrosomia. Obstet Gynecol. 2013; reaffirmed 2015; 128(5):e195- e209. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2016/11000/Practice_Bulletin_No__173___Fetal_Macr osomia.51.aspx. 3. Copel JA and Bahtiyar MO. A practical approach to fetal growth restriction. ObstetGynecol. 2014;123(5):1057-1069. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2014/05000/A_Practical_Approach_to_Fetal_Growth_R estriction.22.aspx. Obstetrical Ultrasound Imaging Guidelines

4. Oros D, Figueras F, Cruz-Martinez R, et al. Longitudinal changes in uterine, umbilical and fetal cerebral Doppler indices in late-onset small-for-gestational age fetuses. Ultrasound Obstet Gynecol 2011 Feb;37(2):191–195. Accessed January 30, 2018. http://onlinelibrary.wiley.com/doi/10.1002/uog.7738/abstract;jsessionid=9CADB1297CC59C7DD4C74 72016BBED65.f01t02?systemMessage=Please+be+advised+that+we+experienced+an+unexpected +issue+that+occurred+on+Saturday+and+Sunday+January+20th+and+21st+that+caused+the+site+t o+be+down+for+an+extended+period+of+time+and+affected+the+ability+of+users+to+access+conte nt+on+Wiley+Online+Library.+This+issue+has+now+been+fully+resolved.++We+apologize+for+any+ inconvenience+this+may+have+caused+and+are+working+to+ensure+that+we+can+alert+you+imm ediately+of+any+unplanned+periods+of+downtime+or+disruption+in+the+future. 5. Cohen E, Baerts W, and van Bel F. Brain-Sparing in intrauterine growth restriction: considerations for the neonatologist. Neonatology. 2015;108:269-276. Accessed November 15, 2017. https://www.karger.com/Article/Pdf/438451. 6. Practice Bulletin 145: Antepartum surveillance 2016. Obstetrics and Gynecology. 2014;124(1):182- 192, reaffirmed in 2016. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Citation/2014/07000/Practice_Bulletin_No__145___Antepartum_ Fetal.35.aspx.

Obstetrical Ultrasound Imaging Guidelines

OB-9: Placental or Cord Abnormalities OB-9.1: Vasa Previa 33 OB-9.2: Placental or Cord Abnormalities 33 OB-9.3: Subchorionic Hematoma or Placental Hematoma 33 OB-9.4: Suspected Abruptio Placentae 34 OB-9.5: Placenta Previa 34 OB-9.6: Placenta Accreta/Placenta Percreta 34 OB-9.6.a: Suspected 34 OB-9.6.b: Known 35

Obstetrical Ultrasound Imaging Guidelines

OB-9.1: Vasa Previa  Vasa previa occurs when membranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie the internal cervical os. Vasa previa can occur on its own or with placental abnormalities, such as a velamentous cord insertion.  Ultrasound (CPT® 76817 and/or CPT® 76815 or CPT® 76816) every 2 to 4 weeks to assess cervical length starting at 28 weeks. If earlier, requests will be sent to Medical Director review.  Amniocentesis is no longer required or recommended for lung maturity.

OB-9.2: Placental or Cord Abnormalities  For the following conditions, ultrasound (CPT® 76817 and/or CPT® 76815 or CPT® 76816) every 2 to 4 weeks starting at 28 weeks until delivery and weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST starting at 32 weeks. If earlier, requests will be sent for Medical Director review.  Placental infarction  Circumvallate shape  Placental hemangioma  Succenturiate placenta or accessory lobe  Chorioangioma  Marginal Cord Insertion

 Velamentous insertion of the umbilical cord

OB-9.3: Subchorionic Hematoma or Placental Hematoma Subchorionic Hematoma or Placental Hematoma First, Second and Third Trimester Ultrasound can be performed for follow-up of a known subchorionic hematoma or placental hematoma (CPT® 76815, or CPT® 76816 if a complete fetal anatomic scan was done previously, and/or CPT® 76817) if the last ultrasound was performed greater than seven days ago. Ultrasound imaging may be repeated earlier than seven days if there are new or worsening symptoms such as an increasing amount of vaginal bleeding or increasing cramping or pain. No further ultrasound is needed if the follow-up ultrasound 7 days following the hemorrhage shows that the hemorrhage has resolved, and there is no further cramping and/or bleeding, and the fetus is growing as determined by size equal dates, in the first trimester. If pregnancy is in second or third trimester follow OB- 9.4: Suspected Abruptio Placentae Obstetrical Ultrasound Imaging Guidelines

OB-9.4: Suspected Abruptio Placentae Suspected Abruptio Placentae Second and Third Trimesters Ultrasound is appropriate for suspected abruptio placentae CPT® 76805 [plus CPT® 76810 if more than one fetus] and/or CPT® 76817 if a complete fetal anatomic scan has not yet been performed during this pregnancy, or  CPT® 76815 for limited ultrasound and/or CPT® 76817, or  CPT® 76816 if a complete fetal anatomic scan was done previously, and/or CPT® 76817 for a transvaginal ultrasound Ultrasound is appropriate to follow-up a known abruption (CPT® 76815 or CPT® 76816 and/or CPT® 76817).  The number and frequency of follow-up ultrasounds will depend on the degree of abruption and the presence or absence of ongoing signs and symptoms

OB-9.5: Placenta Previa Placenta Previa Second and Third Trimesters For suspected placenta previa ultrasound can be performed (CPT® 76805 [plus CPT® 76810 if more than one fetus] (and/or CPT® 76817) if a complete fetal anatomic scan has not yet been performed during this pregnancy or CPT® 76815 for limited ultrasound and/or CPT® 76817 or CPT® 76816 if a complete fetal anatomic scan was done previously and/or CPT® 76817 for a transvaginal ultrasound) For known placenta previa, one routine follow-up ultrasound can be performed at 28 to 32 weeks (CPT® 76815 or CPT® 76816 and/or CPT® 76817). If placenta previa is still present, one follow-up ultrasound (CPT® 76815 or CPT® 76816 and/or CPT® 76817) can be performed at 35 to 37 weeks. Amniocentesis is no longer required or recommended for lung maturity. If persistent placenta previa, BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST weekly, starting at 32 weeks. Follow-up ultrasound can be performed at any time if bleeding occurs BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 or CPT® 76816 and/or CPT® 76817).

OB-9.6: Placenta Accreta/Placenta Percreta OB-9.6.a: Suspected  For suspected placenta accreta, ultrasound can be performed at > 32 weeks, or 1 to 2 weeks prior to planned delivery for surgical planning (CPT® 76805 [plus CPT® 76810 if more than one fetus] (and/or CPT® 76817) if a complete fetal anatomic scan has not yet been performed or  CPT® 76815 for limited ultrasound and/or, CPT® 76817, or  CPT® 76816 if a complete fetal anatomic scan was done previously, and/or CPT® 76817 for a transvaginal ultrasound)  If the ultrasound is inconclusive or equivocal, send to MD review Obstetrical Ultrasound Imaging Guidelines

OB-9.6.b: Known  For known placenta accrete/percreta, follow up growth ultrasounds can be performed every 2 to 4 weeks (CPT® 76816 and/or CPT® 76817)  BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST weekly, starting at 32 weeks  Follow-up ultrasound can be performed at any time if bleeding occurs (CPT® 76815 and/or CPT® 76817)  MD can approve Pelvic MRI without contrast (CPT® 72195) if indicated the ultrasound is indeterminate or advanced imaging is needed for surgical planning. If only placenta or maternal pelvis is imaged without fetal imaging

Practice Note When there are ambiguous ultrasound findings or suspicion of a posterior placenta accreta, with or without placenta previa, ultrasound may be insufficient. MRI is able to outline the anatomy of the invasion and relate it to the regional anastomotic vascular system and enable confirmation of parametrial invasion and possible ureteral involvement.

References 1. Committee Opinion No. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol. 2013 May:121(4):908-910. reaffirmed 2015. Accessed November 3, 2017. http://journals.lww.com/greenjournal/Fulltext/2013/04000/Committee_Opinion_No__560___Medically_I ndicated.45.aspx. 2. Practice Bulletin 134: Fetal Growth Restriction. Obstet Gynecol. 2013, reaffirmed 2015; 121(5):1122- 1133. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2013/05000/Practice_Bulletin_No__134___Fetal_Growt h.45.aspx. 3. Committee Opinion No. 529: Placenta accrete. Obstet Gynecol. 2012;120:207–11, reaffirmed 2017. Reaffirmed 2017 Accessed November 3, 2017. http://journals.lww.com/greenjournal/Citation/2012/07000/Committee_Opinion_No__529___Placenta_ Accreta.42.aspx. 4. Kilcoyne A, Shenoy-Bhangle AS, Roberts DJ, et al. MRI of placenta accreta, placenta increta, and placenta percreta: pearls and pitfalls. Am J Roentgenol. 2017Jan;208(1):214-221. Accessed January 30, 2018. https://www.ajronline.org/doi/abs/10.2214/AJR.16.16281. Obstetrical Ultrasound Imaging Guidelines

OB-10: Fetal Aneuploidy and Anomaly Screening OB-10.1: First Trimester Screening 37 OB-10.2: Second Trimester Screening 38

OB-10.1: First Trimester Screening  First trimester nuchal translucency is not necessary if cfDNA is done  First trimester screening includes biochemical markers and fetal nuchal translucency (FNT) (CPT® 76813). Conducted together, these screenings can identify risk for specific chromosomal abnormalities (e.g. Down’s syndrome, Trisomy-18)  Nuchal translucency is completed between 11 and 13 6/7 weeks (CRL between 44 and 83 millimeters). An abnormal Fetal Nuchal Translucency scan, with a nuchal translucency measurement of ≥ 3.0 mm, may indicate an increased risk for cardiac defects, abdominal wall defects, diaphragmatic hernia, and genetic syndromes in euploid fetuses; whereas, a nuchal translucency ≥ 2.5mm may indicate an increased risk for aneuploidy (imaging should be based upon the MOM for NT and biochemical markers).  “… the use of ultrasound codes CPT® 76801/ CPT® 76802 should be indication driven and should not be routinely done whenever an ultrasound for nuchal translucency (CPT® 76813/ CPT® 76814) is requested. In cases where there is either a maternal and/or fetal indication then the CPT® 76801 code can indeed be billed along with the nuchal translucency screening (CPT® 76813/ CPT® 76814).” (Society for Maternal-Fetal Medicine) First Trimester Screening:  Ultrasound is the initial imaging for the first trimester screening, to evaluate fetal nuchal translucency

 If the nuchal translucency is abnormal, the following tests can be performed:  Fetal anatomic ultrasound(CPT® 76811) at 16 weeks or greater weeks  Amniocentesis  CVS  Fetal echocardiogram (NT ≥ 3.0 mm)  Abnormal FNT with normal aneuploidy screen and normal chromosomes (as measured by chorionic villus sampling or amniocentesis) should be evaluated with a fetal echo (CPT® 76825 and/or CPT® 76827 and/or CPT® 93325) and fetal ultrasound (CPT® 76811)

Coding Notes  CPT® 76813 and CPT®76814 should be performed only by those certified by the Fetal Medicine Foundation or Nuchal Translucency Quality Review Program (NTQR)  Report as CPT® 76813 (plus CPT® 76814 if more than one fetus)  CPT® 76813 can be performed once per pregnancy if the pregnancy is 11 to 13 6/7 weeks  If FNT is abnormal, CPT® 76811 is usually performed by a Maternal Fetal Medicine (MFM) specialist, Perinatologist, Radiologist, or facility/physician with AIUM certification (with advanced training in fetal imaging) after 16 weeks  The use of ultrasound codes (CPT® 76801/CPT® 76802) should be indication driven and should not be routinely done whenever an ultrasound for nuchal translucency Obstetrical Ultrasound Imaging Guidelines

(CPT®76813/CPT®76814) is requested. In cases where there is either a maternal and/or fetal indication, then the CPT® 76801 code can indeed be billed along with the nuchal translucency screening (CPT®76813/CPT®76814)

OB-10.2: Second Trimester Screening See also: OB-5.1: Initial Screening for Fetal Anomalies

Two studies, a quad screen and ultrasound, are done during the second trimester to detect fetal aneuploidy, neural tube defects, and other anatomical defects. A fetal anatomic scan to screen for anomalies is ideally performed at 18 to 20 weeks, 1. but may be performed after week ≥ 16. If less than 16 weeks, send to MD review. If the quad screening is abnormal, an ultrasound (CPT® 76811) may also be 2. performed.

Practice Notes Multiple marker screening is used in the second trimester (15 to 20 weeks) to screen for trisomies 21 and 18 as well as open neural tube defects (ONTD). The “quad” screen is the most commonly used test for the second trimester. The quad screen measures four substances:

1. AFP (alpha-fetoprotein) 2. hCG (human chorionic gonadotropin) 3. uE (Unconjugated estriol0 4. dimeric inhibin-A

A penta screen may be done in lieu of a quad screen, the penta screen includes hyperglycosylated hCG in addition to the quad screen markers. The “penta” screen measures five substances: 1. AFP 2. hCG 3. hyperglycosylated hCG 4. uE 5. dimeric inhibin-A

Maternal serum alpha-fetoprotein (MSAFP) can be done at 15 to 20 weeks to screen for neural tube defects if quad or penta is not performed. Obstetrical Ultrasound Imaging Guidelines

Combined, integrated or sequential screening (first and second trimester screening) may also be used and provides a higher detection rate than a single screening. Providers often wait for the results of the quad screen before ordering CPT® 76805. If the quad screen is abnormal, they may request CPT® 76811 in lieu of CPT® 76805.

Cell Free DNA Testing-cfDNA First trimester nuchal translucency screening is not necessary if cfDNA is performed. Testing can be offered as early as the 10 week of pregnancy. Cell free fetal DNA (cfDNA) has been noted to be the most sensitive test for Down syndrome per the American College of Medical Genetics and Genomics. With a negative cfDNA test, it is very unlikely the fetus has trisomy 21, 13 or 18. Other chromosomal abnormalities may also be identified. The sex and Rh status of the baby may be included. The American College of Medical Genetics and Genomics (ACMG) recommends against using this test to screen for microdeletions or any autosomal aneuplodies other than 13, 18 and 21. A woman with a positive cfDNA should be offered diagnostic testing (amniocentesis or CVS). A detailed anatomy scan 76811 is indicated at 16 weeks or greater. (See also: OB-11.1: High Risk Group One-Risk Factors).

A “no call” or indeterminate result can occur (risk is higher with maternal obesity), but this has a higher risk of chromosomal abnormality than a normal result. The patient should be offered amniocentesis or CVS testing. Note that cfDNA does not screen for neural tube defects. Patients should be offered screening for open neural tube defects with maternal serum AFP (MSAFP) or ultrasound (usual anatomy scan-76805 or 11 depending on risk factors) References 1. Practice Bulletin: No.187: Neural Tube Defects. Obstet Gynceol. 2017 Dec;130(6):e279-e290. Accessed January 30, 2018. https://journals.lww.com/greenjournal/Abstract/2017/12000/Practice_Bulletin_No__187___Neural_Tu be_Defects.41.aspx 2. Society for Maternal and Fetal Medicine (SMFM), coding committee, October 2017. SMFM’s white paper on billing combination of 76801 and 76813. 3. Practice Bulletin No.162: Prenatal diagnostic testing for genetic disorders. Obstet Gynecol. 2016 May; 127(5):e108-e122. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Citation/2016/05000/Practice_Bulletin_No__2___Prenatal_Diagn ostic.40.aspx. 3. Practice Bulletin No. 163: Screening for fetal aneuploidy. Obstet Gynecol. 2016 May;127(5):e123- e137. Accessed November 15, 2017. http://journals.lww.com/greenjournal/Abstract/2016/05000/Practice_Bulletin_No__163___Screening_f or_Fetal.41.aspx.. 4. Practice Bulletin No. 175: Ultrasound in pregnancy. 2016 Dec;128(6):e241-e256. Accessed November 15, 2017. Obstetrical Ultrasound Imaging Guidelines

http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2016&issue=12000&article=0005 3&type=Fulltext. 5. Committee Opinion No. 640: Cell-free DNA screening for fetal aneuploidy. Date of Origin: September 2015, reaffirmed 2017. Accessed November 15, 2017. https://www.acog.org/-/media/Committee- Opinions/Committee-on-Genetics/co640.pdf?dmc=1&ts=20171115T1734510447. 6. Gregg AR, Skotko BG, Benkendorf JL et al. Noninvasive prenatal screening for fetal aneuploidy 2016 update: a position statement of the ACMGG. American College of Medical Genetics and Genomics. Accessed November 15, 2017. https://www.nature.com/articles/gim201697.pdf. 7. AJOG/SMFM: Consult series number 42. The role of ultrasound in women who undergo cell-free DNA screening. 2017; 216(3)B2-B7. Accessed November 15, 2017. https://www.sciencedirect.com/science/article/pii/S0002937817301059. 8. Society for Maternal-Fetal Medicine (SMFM), Norton ME, Bittio JR, Juller, JA, et al. The role of ultrasound in women who undergo cell-free DNA screening. Am J Obstet Gynceol. 2017 Mar;216(3):B2-B7. Accessed January 30, 2018. http://www.ajog.org/article/S0002-9378(17)30105- 9/fulltext. 9. Donofrio MT, Moon-Grady AJ, Hornberger LK et al. Diagnosis and treatment of fetal cardiac disease: A scientific statement from the American Heart Association. Circulation, 2014;129(21):2183-242. Accessed November 15, 2017. https://www.medscape.com/medline/abstract/24763516.

Obstetrical Ultrasound Imaging Guidelines

OB-11: High Risk Pregnancy High Risk Pregnancy Special Considerations 42 OB-11.1: High Risk Group One-Risk Factors 43 Socio-Demographic Risk Factors 43 Lifestyle Related Risk Factors 43 Health Condition Related Risk Factors 43 Previous pregnancy related risk factors 44 Current pregnancy related risk factors 44 Maternal Infections 44 OB-11.2: High Risk Group Two – Findings on Ultrasound 45 11.2.a: High Risk Group Two a. 45 11.2.b: High Risk Group Two b. 45 OB-11.3: High Risk Group Three – BMI 45 11.3.a: Pre-pregnancy BMI 30 to 34 45 11.3.b: Pre-pregnancy BMI 35-39 46 11.3.c: Pre-pregnancy BMI ≥ 40 46 OB-11.4: High Risk Group Four 47 11.4.a: Prior Pregnancy with Macrosomia 47 11.4.b: Current Pregnancy with Macrosomia 47 OB-11.5: High Risk Group Five: Zika Virus 47 OB-11.6: High Risk Group 6- Pre-Gestational Diabetes On oral medications or insulin 48 OB-11.7: High Risk Group Seven Gestational Diabetes 50 OB-11.7.a: Gestational Diet Controlled 50 OB-11.7.b: Gestational Diabetes on Oral Medications or Insulin 51 OB-11.8: Hypertension 52 OB-11.9: Single Umbilical Artery 53 OB-11.10: History of Pre-Term Delivery/History Of PPROM 53 OB-11.10.a: Preterm Delivery ≤ 34 Weeks History Of PPROM ≤ 34 weeks 53 OB-11.10.b: History of Preterm Delivery > 34 weeks 54 OB-11.11: History of Stillbirth 54

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Obstetrics & Gynecology. Obstetrics Pregnancy. in Hemoglobinopathies 78: No. Bulletin tice ; - ;123(5):1057 ;

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OB-12: History of Infertility OB-12.1: History of Infertility 59 OB-12.2: Present Pregnancy with Use of Fertility Drugs and Treatment (ART) 59

______© 2018 eviCore healthcare. All Rights Reserved. Page 58 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400  ______ (ART) Treatment and Drugs Fertility of use with Pregnancy Present OB-12.2:  OB-12.1: History of Infertility Guidelines Imaging 8 © 201 Repeat ultrasound is not usually necessary unless there are new clinical indications ultrasound Follow high risk imaging, OB imaging, risk high Follow 76801 Ultrasound imaging is supported if there is a history infertility of treatment (CPT . All Rights Reserved. Rights All . healthcare eviCore

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OB-13: Cervical Insufficiency/Current Preterm Labor OB-13.1: Cervical Insufficiency 61 OB-13.2: Cerclage in place in current pregnancy 61 OB-13.3: Current Preterm Labor 62

______© 2018 eviCore healthcare. All Rights Reserved. Page 60 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______    placeCerclageOB- 13.2: in pregnancy incurrent CervicalOB- 13.1: Insufficiency PPROM For history of pre - Guidelines Imaging 8 © 201 Presence of uterinePresence anomaly (See: prior of History delivery precipitous 24 until weeks weeks 76817) for transv for 76817) (CPT ultrasoundcm)25 is mmfound, (2.5 cervixabnormally≤ orshorten If funneling Excision [LEEP]) Procedure Electrosurgical traumaSurgical to— cervix (e.g. conization [CKC laceration apreviousCervicalfrom obstetrical delivery dilation ofOver cervix a of pregnancytermination during pregnancy) Perso Masses Adnexal/Pelvic every76815) 2 4to and/or weeks is Ultrasound supported 16at or weeks greater: CPT more thanmore one and/orfetus] Starting after theStarting anatomic at 16 scan fetal weeks or greater, nothas yet been performed during pregnancy. this weeks a if rescue cerclage was placed. Transvaginal (CPT 768 Starting after the fetal anatomic scan at 16 weeks or greater, ultrasound (CPT scan has not been done. more than one fetus] and/or CPT Ultrasound is supported at 16 weeks or greater: CPT weeks) any for one of the following: and/or CPT limited ultrasoundcompleteifa ultrasound76801 has alreadybeen performed ultrasound Ultrasound CPT ® nal history cervical of (without placement insufficiency cerclage in the current . All Rights Reserved. Rights All . healthcare eviCore 15 or CPT 76816) every 2to 4 weeks thefor duration pregnancyof the and/or

has not yethas not beenperformed oncein firsttrimester, or ®

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 3. 11. 6. 5. 4. ______12. 10. 9. 8. 7. 2. 1. References    Labor Preterm Current OB-13.3: Guidelines Imaging 8 © 201 Orzechowski KM, Boelig RC, Baxter JK, et JK, al Baxter RC, Boelig KM, Orzechowski 2017. https://www.ncbi.nlm.nih.gov/pubmed/22542113 2017. - 2016;128(6):1459 & Gynecology. Obstetrics pregnancy. in Ultrasound Summary: 175: No. Bulletin Practice - Pre of Management 171: Bulletin Practice ACOG 2016. reaffirmed 2012, October Birth. Preterm of Prevention and Prediction 130: No. Bulletin Practice ACOG pr quan G h T as JAMA select in screening length cervical routine of role The al. V et Berghella H, Feltovich J, McIntosh H.J. Roh, and H.J. Cho, - 2012;206(5):376 Gynecol. Obstet J Am practice. clinical into data trials Maternal for Society 2016. reaffirmed 2014, February insufficiency. cervical of management the for Cerclage 142: No. Bulletin Practice ACOG and AT, Tita ES, Miller Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths a lengths cervical transvaginal serial of accuracy Predictive al. et JD, Iams MA, Elovitz MS, Esplin Obstetrics & or en.pdf bronectin%20levels%20for%20spontaneous%20preterm%20birth%20among%20nulliparous%20wom %20serial%20transvaginal%20cervical%20lengths%20and%20quantitative%20vaginal%20fetal%20fi https://www.rtihs.org/sites/default/files/28462%20Hunter%202017%20Predictive%20accuracy%20of - 9378(16)30112 Ultrasound_in.50.aspx http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ review. MD Once or when symptomatic, biophysical profile (BPP) (CPT CPT 76815 this pregnancy; if a complete fetal anatomic scan was performed previously, CPT CPT For contractions, CPT Jain S, Kilgore M, Edwards, RK, et al. Revisiting the cost the Revisiting al. et RK, Edwards, M, Kilgore S, Jain D prevention. birth preterm in screening length cervical for approach Ultrasound Carlson Laura and Stamilio, David Berghella, Vincenzo Adeeb, Khalifeh, – 35:537 - http://www.ajog.org/article/S0002 2017. 6, December Accessed s http://onlinelibrary.wiley.com/doi/10.7863/ultra.15.03026/epdf creening: importance of progesterone efficacy. efficacy. progesterone of importance creening: igh Journal of Ultrasound in Medicine. 2016; Medicine. in Ultrasound of Journal Birth. Preterm Predicting for Sonography ransvaginal - 215(3):B2 2016; ynecology. ogram for preterm birth prevention. Obstetrics and Gynecology and Obstetrics prevention. birth preterm for ogram - 126:61 2015; & Gynecology, Obstetrics women. ymptomatic

AFI CPT AFI . All Rights Reserved. Rights All . healthcare eviCore - - titative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. nulliparous among birth preterm spontaneous for levels fibronectin fetal vaginal titative ® ® and low and - 2017:317(10):1047 . . 76817 once or when symptomatic. 76817 if acomplete fetal anatomic scan has not yet been performed during 544. or or CPT

- 739 Gynecology Accessed November 15, 2017. 15, November Accessed - ® risk women for preterm birth prevention. American Journal of Obstetrics of Journal American prevention. birth preterm for women risk

76815 with 0/fulltext ® 1460. Accessed November 15, 2017. 15, November Accessed 1460. 76816 - Fetal Medicine. Progesterone and preterm birth prevention: translating clinical translating prevention: birth preterm and Progesterone Medicine. Fetal . - Second WA. Grobman Correlation Between Cervical Lengths Measured by Transabdominal an Transabdominal by Measured Lengths Cervical Between Correlation . ®

Accessed December 6, 2017. 6, December Accessed 1056. (76816 no more than every 2weeks)when symptomatic 76805 [plus CPT NST, starting at 30 weeks; if less than 30 weeks send to 744. B7. Accessed November 15, 2017. 2017. 15, November Accessed B7.

. A universal transvaginal cervical length screenin length cervical transvaginal universal A . trimester cervical length screening am screening length cervical trimester A J Obstet Gynecol Obstet A J ® Term Labor. October 2016. October Labor. Term 76810if more than onefetus] . ec -

effectiveness of universal cervical lengt cervical universal of effectiveness 2016; 215(6) American Journal of Journal American 215(6) 2016; 8924 8924 . 66. - 9378(16)00215 . http://ww 2014;124:520 . 2016 Jul; 2016 . ® 386. Accessed November 15, November Accessed 386. 76818

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- 14: Intrauterine Device (IUD) Device Intrauterine 14:

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ anLocateOB-Device 14.1: Intrauterine Guidelines Imaging 8 © 201  and/or CPT Ultrasound can be performed to locate an intrauterine device (IUD) (CPT

76817 if a complete ultrasound has not yet been performed) and/or

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-15: Macrosmia  See: OB-8.2: Macrosomia-Large for Dates Macrosomia  See: OB-11.4: High Risk Group Four

Obstetrical Ultrasound Imaging Guidelines

OB-16: Multiple Pregnancies OB-16.1: For Suspected multiple pregnancies: 67 OB-16.2: For Known dichorionic multiple pregnancies 67 OB-16.3: For Known monochorionic-diamniotic or monochorionic- monoamniotic multiple pregnancies 68

Obstetrical Ultrasound Imaging Guidelines

OB-16: Multiple Pregnancies OB-16.1: For Suspected multiple pregnancies:  Ultrasound is appropriate to confirm suspected multiple pregnancy (CPT® 76801[plus CPT® 76802 if more than one fetus]) if less than 14 weeks. OB-16.2: For Known dichorionic multiple pregnancies:  CPT® 76811[plus CPT® 76812 if more than one fetus] if greater than 14 weeks if a complete detailed anatomic scan CPT® 76811 has not yet been performed during this pregnancy  Follow-up ultrasounds for all known dichorionic multiple pregnancies (CPT® 76816 and/or CPT®76817):  Ultrasound (CPT® 76816) every 4 to 6 weeks to assess fetal growth starting at 23 to 24 weeks gestation  Transvaginal ultrasound (CPT® 76817) is recommend only in twin gestations with significant cervical shortening <= 1.5 cm on a transabdominal evaluation if rescue cerclage is a consideration. Send all these requests to MD Review  Weekly BPP (CPT® 76818 or CPT® 76819) or 76815 for AFI with NST, starting at 32 weeks or sooner if additional risk factors  Twice weekly BPP can be considered in rare clinical circumstances. These requests will be forwarded for Medical Director review  If discordant twins ≥ 20%. See practice note below. Twice weekly BPP plus ultrasound (CPT® 76816) every 2 to 4 weeks, and umbilical artery Doppler (CPT®

78620) weekly; for twice weekly imaging send to MD review  If FGR is diagnosed, weekly umbilical artery Doppler and/or Middle Cerebral Artery Doppler (CPT® 76820 and/or CPT® 76821)  If IVF dichorionic twins, report initial fetal echo as CPT® 76825 and/or CPT® 76827 and/or CPT® 93325. Transabdominal fetal echo is usually not performed prior to 16 weeks. Follow-up echo requests will be sent to Medical Director review  If other high risk factors, see OB-11: High Risk Pregnancy Obstetrical Ultrasound Imaging Guidelines

OB-16.3: For Known monochorionic-diamniotic or monochorionic- monoamniotic multiple pregnancies  CPT® 76811 [plus CPT® 76812 if more than one fetus] if greater than 14 weeks if a complete detailed anatomic scan CPT® 76811 has not yet been performed during this pregnancy.  Ultrasound (CPT® 76816) every 2 to 4 weeks to assess fetal growth starting at 16 weeks gestation  Transvaginal ultrasound (CPT® 76817) is recommend only in twin gestation with significant cervical shortening <= 1.5 cm on a transabdominal evaluation if rescue cerclage is a consideration. Send all these requests to MD Review  Weekly BPP (CPT® 76818 or CPT® 76819) or CPT® 76815 for AFI with NST, starting at 32 weeks, sooner if additional risk factors are present.  Fetal middle cerebral artery (MCA) Doppler (CPT® 76821) every 2 to 3 weeks starting at 16 weeks to monitor for twin-twin transfusions syndrome (TTTS) and may be continued every 2 to 3 weeks to monitor for twin anemia polycythemia sequence (TAPS) until delivery. If Twin to Twin Transfusion syndrome is suspected due to one twin failing to grow compared with the other twin, daily evaluation (CPT® 76815), and/or CPT® 76818 or CPT® 76819) and/or umbilical artery Doppler (CPT® 76820) can be performed to aid in planning intervention and/or imminent delivery  If discordant twins ≥ 20%. See practice note below Twice weekly BPP plus ultrasound (CPT® 76816) every 2 to 4 weeks, and umbilical artery Doppler (CPT® 78620) weekly.  Daily fetal testing may be indicated if umbilical Doppler is abnormal. These requests will be forwarded for Medical Director for review.  Fetal echo CPT® 76825 and/or CPT® 76827 and/or CPT® 93325 for initial echo. Transabdominal fetal echo is usually not performed prior to 16 weeks. For follow-up echo, send to MD review.  If FGR is diagnosed, weekly umbilical artery Doppler and/or Middle Cerebral Artery Doppler (CPT® 76820 and/or CPT® 76821)  If other high risk factors, see OB-11: High Risk Pregnancy  Triplets or higher Multiple Pregnancy receive same imaging as monochorionic- diamniotic- and monochorionic- monoamniotic- twins.  These requests will be forwarded for Medical Director review.

Practice Notes Discordant twins Birth weight discordance = (larger twin weight minus smaller twin weight) divided larger twin weight × 100. Cervical length screening is not recommended in twin gestation. The use of a rescue cerclage when cervical dilation is present has shown to be beneficial. For this reason a cervical length under 1.5 cm is required for evaluation. In select cases a TV ultrasound may be indicated. These require approval from the Medical Director. Cerclage is use for TTTS case due to polyhydramnios causing the short cervix. Also rescue cerclage is still use in those with a dilated cervix. Obstetrical Ultrasound Imaging Guidelines

References 1. Practice Bulletin No. 169: Multiple gestations: twin triplet and higher order multi fetal pregnancies. 2016;128(4):e131-146. Obstetrics & Gynecology. Accessed November 16, 2017. http://journals.lww.com/greenjournal/Abstract/2016/10000/Practice_Bulletin_No__1 69___Multifetal_Gestations.59.aspx. 2. Practice Bulletin No. 175 Summary: Ultrasound in Pregnancy. Obstet Gynecol. 2016;128(6):1459-1460. Accessed November 3, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__1 75_Summary___Ultrasound_in.50.aspx 3. Khalil A, Rodgers M, Baschat A, et al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol. 2016;47(2):247–263. Accessed November 16, 2017. http://onlinelibrary.wiley.com/doi/10.1002/uog.15821/epdf.

Obstetrical Ultrasound Imaging Guidelines

OB-17: Previous C-section OB-17.1: Previous C-section 71

______© 2018 eviCore healthcare. All Rights Reserved. Page 70 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______OB-17.1 Guidelines Imaging 8 © 201 has already been performed and/or CPT (CPT One growth scan (CPT be performed after 16 weeks, if earlier send to MD Review. 76805 for fetal anatomic scan is ideally performed between 18 to 20 weeks, but must indicated if less than 14 weeks. not yet been performed, OR CPT CPT ultrasoundOne be can performed to confirm dates If patient has had a previous Cesarean ® ® ® . All Rights Reserved. Rights All . healthcare eviCore 76801 [plusCPT 76816) : Previous C Previous

76816) a 76816) ® -section 76802 if more than one fetus] if acomplete ultrasound has t 32t and weeks one scan betweengrowth 36and 38weeks

76815 for limited ultrasoundifcomplete ultrasound

section 76817 for atransvaginal ultrasound

8924 8924

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OB-18: Post Date Pregnancy OB-18.1: Post Date Pregnancy 73

______© 2018 eviCore healthcare. All Rights Reserved. Page 72 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Reference found to be useful. In post Practice Note PostOB-Date18.1: Pregnancy Guidelines Imaging 8 © 201 with NST at 41 weeks or greater Then with NST, starting at 40 weeks Weekly biophysical profile evaluate fetalgrowth Follow Gynecology - Late of Management 146: No. Bulletin Practice nt_of.34.aspx http://journals.lww.com/greenjournal/Abstract/2014/08000/Practice_Bulletin_No__146___Manageme

. 2014; .

- 124(2):390

(CPT ® 396, reaffirmed 2016. Accessed November 16, 2017. 2017. 16, November Accessed 2016. reaffirmed 396, 76816) everyweeks 2 ( ® 76818 or CPT ®

76818 or CPT

Term and Post and Term ® 76819)CPT or ®

76819) or CPT > 8924 8924 40 weeks gestation) to - Term Pregnancies Term ® ® 76815AFI for ®

93976) has not been

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OB-19: Preterm/Premature Rupture of Membranes OB-19.1: Preterm Premature Rupture of Membranes (PPROM) 75 OB-19.2: Premature Rupture of Membranes (PROM) 75

______© 2018 eviCore healthcare. All Rights Reserved. Page 74 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______3. 2. 1. References  PrematureOB-Rupture19.2: of (PROM) Membranes  PretermOB- 19.1: Premature See also: See also: Guidelines Imaging 8 © 201   2012 Accessed November 16, 2017. 2017. 16, November Accessed – 2016;128(4):e155 - Pre of Management 171: No. Bulletin Practice 2017. 16, November Accessed 77. 172: No. Bulletin Practice 130: No. Bulletin Practice 62&type=Fulltext http://journals.lww.com/gr nd.42.aspx http://journals.lww.com/greenjournal/Citation/2012/10000/Practice_Bulletin_No__130___Prediction_a for review. Greater than or equal to review. Less than or equal to 36 6/7 weeks. Requests will be forwarded to Medical Director

rare cases outpatient monitoring has been performed (refer to Medical Director OB OB

. - -

13.2: 13.2: 4:

Amniotic Fluid Abnormalities/ Oligohydramnios/ Oligohydramnios/ Abnormalities/ Amniotic Fluid

. 973, 64. Replaces Practice Bulletin Number 159, January 2016 (Interim Update) (Interim 2016 January 159, Number Bulletin Practice Replaces 64. Cerclage in place in current pregnancy current in place in Cerclage

reaffirmed 2016. Accessed November 15, 2017. 2017. 15, November Accessed 2016. reaffirmed

eenjournal/Pages/articleviewer.aspx?year=2016&issue=10000&article=000 Premature Rupture of Membranes. of Rupture Premature Birth. Preterm of andPrevention Prediction 37 weeks. Requests will be forwarded to Medical Director . https://www.medscape.com/medline/abstract/27661654 Rupture of Membranes (PPROM) Membranes of Rupture

term Labor. Obstetrics Labor. &term Gynecology. October 8924 8924

Obstet Gynecol Obstet Obstetrics & Gynecology & Obstetrics

- Oct;128(4):e165 2016 . Polyhydramnios www.eviCore.com Page 75of108

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-20: Third Trimester Imaging OB-20.1: Third Trimester Imaging - Ultrasound 77

OB-20.1: Third Trimester Imaging – Ultrasound Imaging in the third trimester is indicated for bleeding, pain, absent fetal heart tone, decreased fetal movement and/or other high-risk indications. (see: OB-11: High Risk Pregnancy ) For suspected breech position, see: OB-2: Abnormal Fetal Position or Presentation

Reference 1. Practice Bulletin No. 175 Summary: Ultrasound in pregnancy. Obstet & Gynecol. 2016;128(6):1459- 1460. Accessed November 3, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ Ultrasound_in.50.aspx.

Obstetrical Ultrasound Imaging Guidelines

OB-21: Uncertain Dates OB-21.1: Uncertain Dates/Unknown Last Menstrual Peroid (LMP) 79

Obstetrical Ultrasound Imaging Guidelines

OB-21.1: Uncertain Dates/Unknown Last Menstrual Peroid (LMP)

The low risk pregnancy that has no other indications for ultrasound should have a Fetal Nuchal translucency (CPT® 76813 completed between 11 and 13 6/7 weeks and a fetal anatomic ultrasound (CPT® 76805) performed at 16 weeks or greater. The timing can be determined by fundal height. (See: OB-5: Fetal Anatomic Scan ). If the patient has had irregular menstrual periods in the year prior to the current pregnancy OR an unknown LMP and has inconsistency in dates between the clinical pelvic exam and history stated dates, one ultrasound can be performed to confirm dates: (CPT® 76801) [plus CPT® 76802 if more than one fetus] and/or CPT® 76817 for a transvaginal ultrasound if less than 14 weeks and a complete ultrasound has not yet been performed. CPT® 76805 plus CPT® 76810 if more than one fetus) if equal to or greater than 14 weeks, when complete fetal anatomic scan CPT® 76805 is planned and has not yet been performed. CPT® 76815 or CPT® 76816 (if a complete anatomy ultrasound was done previously and was inconclusive for confirming pregnancy dates, and/or CPT® 76817 for a transvaginal ultrasound)

References 1. Practice Bulletin No. 175 Summary: Ultrasound in pregnancy. Obstet & Gynec. 2016;128(6):1459-1460. Accessed November 16, 2017. http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No_ _175_Summary___Ultrasound_in.50.aspx. 2. Reddy UM, Abuhamad AZ, Levine D, et al. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society of Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Obstet Gynecol Survey. 2014; 69(8):453-455. Accessed November 16, 2017. http://journals.lww.com/obgynsurvey/Abstract/2014/08000/Fetal_Imaging___Exe cutive_Summary_of_a_Joint.4.aspx. Obstetrical Ultrasound Imaging Guidelines

OB-22: Unequal Fundal Size and Dates OB-22.1: Unequal Fundal Size and Dates 81

OB-22.1: Unequal Fundal Size and Dates

Unequal fundal size is defined as more than a 3 week difference in fundal height and gestational age at 23 weeks gestation or greater. One ultrasound can be performed (CPT® 76805) if complete fetal anatomic scan is 1. planned and has not been performed or CPT® 76816 if CPT® 76805 complete anatomic scan or detailed ultrasound CPT® 76811 has been done previously.

References 1. Pay A, Frøen JF, Staff AC, et al. Prediction of small-for-gestational-age status by symphysis-fundus height: a registry-based population cohort study. BJOG. 2016;123:1167 2. BMC Pregnancy Childbirth. 2015 Feb 10;15:22. Symphysis-fundus height measurement to predict small-for-gestational-age status at birth: a systematic review. 3. ACOG practice bulletin 134. Fetal growth restriction. May 2013, reaffirmed in 2015

Obstetrical Ultrasound Imaging Guidelines

OB-23: Uterine Anomalies/Adnexal/Pelvic Masses/Ovarian Cysts or Mass OB-23.1: Uterine Anomalies or Adnexal/Pelvic Masses 83

______© 2018 eviCore healthcare. All Rights Reserved. Page 82 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______with fibroids of the lower uterine segment. commonly found small fibroids. Finally, malposition or obstructed labor is associated Fetal compression syndrome is a direct result of large fibroids and is not associated with when the fibroid volume is >200 cm appear to be any association of fetal growth restriction with Placentation over a fibroid appears to be strong risk factor for abruption. There does not abruption has been reported to occur frequently in pregnancies complicated by fibroids. the size of the fibroid (over 600cm3) and/or the presence of multiple fibroids. Placental and fetal compression syndromes. The risk of preterm labor appears to correlate with These complications relate to preterm labor, placental abruption, fetal growth restriction, being the most frequent complications. The major concerns occur late in pregnanc in several ways, with abdominal pain, miscarriage, malpresentation, and difficult delivery r pregnancy has little or no effect on the overall size of fibroids despite the occurrence of from as low as 0.1% of all pregnancies to higher rates of 12.5%. It seems that The true incidence of fibroids during pregnancy is unknown. The reported rates vary Practice Note Adnexal/PelvicUterineOB- 23.1: Anomaliesor Masses Guidelines Imaging 8 © 201 ed degeneration in early pregnancy. Fibroids, however, affect pregnancy and delivery is of concern.isof If follow Advanced imaging Advanced willrequests imaging besent to Medical review. Director present then proceed with monitoring per guidelines. volume > 200cm3 – and a repeat ultrasound at 34 to 36 weeks gestation (for those with fibroi Ultrasound (CPT Insufficiency/Current Preterm Labor Transvaginal ultrasound (CPT OB Fetal anatomic scan at 16weeks or greater (CPT Moderate (>200cm a76816 if complete scanfetal anatomic was done previously. anatomic complete hasscan fetal not yet been performed, or CPT Second or CPT third trimester: ultrasoun transvaginal acompleteIf ultrasound was donepreviously CPT performed. a76817 if transvaginal for aultrasound has complete notultrasound yet been First trimester: adnexal/pelvic mass. can be Ultrasound performed a for known or uterine suspected anomaly and/or - 11: High11: Risk . All Rights Reserved. Rights All . healthcare eviCore

CPT

® ® 76815 or CPT 3)

Pregnancy 76801 [plus CPT76801 [plus

d. and Large 600 (over cm associated with increased risk of FGR see below). If FGR is -

up of cervical length is needed, see: ®

76805 [plus CPT 76805 [plus ® — 76817) if pre- ® CPT 76816) may beconsidered at 28 to 30 weeks 3 ®

fetal growth restriction appears more commonly. 76802 if more onethan and/or CPTfetus] ®

76811)

3 ) Leiomyomata (fibroid) Leiomyomata (fibroid) ) ® term labor or cervical insufficiency

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76815 and/or CPT ® 76805 or if meets criteria in 8924 8924

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______5. 4. 3. 2. 1. References Guidelines Imaging 8 © 201 https://www.scribd.com/document/329485720/Contemporary N ex N O Lee HJ, Norwitz ER, Norwitz Lee HJ, https://www.ncbi.nlm.nih.gov/pubmed/18395031 2017. 16, delivery. to conception from review AB Caughey ND, Tran PC, Klatsky - second routine at Leiomyomas al. AS, et Graseck AO, Odibo MJ, Stout - anultrasound pregnancy: of trimester first in the leiomyomas uterine of Prevalence al. et DA, Savitz DD, Baird SK, Laughlin 2006; . Gynecol Obstet leiomyomata. uterine identified AB, Caughey GI, Qidwai - second quarterly/Citation/2006/06000/Obstetric_Outcomes_in_Women_with_Sonographically.10.aspx - http://journals.lww.com/ultrasound ovember 16, 2017. 2017. 16, ovember 2017. 16, ovember bstetrics andGynecology bstetrics Obstet Gynecol Obstet outcomes. obstetric adverse and amination . All Rights Reserved. Rights All . healthcare eviCore trimester

- - ultrasound

and https://insights.ovid.com/pubmed?pmid=19300327 http://www.fibroidsecondopinion.com/2010/11/fibro

Jacoby AF. Obstetric outcomes in women with sonographically with women in outcomes Obstetric AF. Jacoby and Reviews i Reviews Pregnancy. in Fibroids of Management Contemporary J. Shaw Obstet Gynecol, Obstet study. screening . - 2010;3(1):20 - examination , Am J Obstet Gynecol. Obstet Am J et al. Fibroids and reproductive outcomes: a systematic literature asystematic outcomes: reproductive and Fibroids al. et and- 27. Accessed November 16, 2017. 16, November Accessed 27.

adverse (2)114. Accessed November 16, 2017. 16, November Accessed 22(2)114. - obstetric

- 2008;198(4)357 .

8924 8924 - 113(3):630 2009; - Management .

20 - outcomes/ 10; 116(5):1056. Access 116(5):1056. . trimester ultrasoun trimester ids

- - 66. Accessed November Accessed 66. . of leiomyomas - Fibroids 635. Access 635. www.eviCore.com Page 84of108 -

in V20.0.2 - at - Pregnancy ed - d ed - routine . 018 n .

Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-24: Procedure Coding Basics for Established Pregnancy OB-24.1: OB Ultrasound Code Selection 87 OB-24.2: Required Elements for First Trimester OB Ultrasound 88 OB-24.3: Required Elements for Second or Third Trimester Fetal Anatomic Evaluation OB Ultrasound 89 OB-24.4: Required Elements for a Detailed Fetal Anatomic Evaluation OB Ultrasound 91 OB-24.5: Fetal Nuchal Translucency 94 OB-24.6: Limited and Follow-Up Studies 95 OB-24.7: Obstetric Transvaginal Ultrasound 96 OB-24.8: Biophysical Profile (BPP) 96 OB-24.9: Fetal Doppler 97 OB-24.10: Duplex Scan (Uterine Artery) 99 OB-24.11: Fetal Echocardiography 101 OB-24.12: 3D and 4D Rendering 102 OB-24.13: Fetal MRI 104

______© 2018 eviCore healthcare. All Rights Reserved. Page 85 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______  identification, during a standard ultrasound procedure, is not separately reimbursable. The minimal use of color Doppler alone, when performed for anatomical structure directionalvascular flow. exclusion includes devices that produce arecord that does not permit analysis of bi is considered part of the physical examination and is not separately billable. This The use of a hand- 3. 2. 1. A Duplex scan describes: Considerations General Pregnancy Established for Basics Coding Procedure Guidelines Imaging 8 © 201        which Ultrasound procedure codes include the preparation of a required final written report ultrasou obstetric All Color flow Doppler imaging Doppler spectral analysis, and mode two dimensional vascular structure, and blood flow in arteries and veins with the production of real time images integrating B An ultrasonic scanning procedure for characterizing the pattern and direction of

. All Rights Reserved. Rights All . healthcare eviCore Only “limited” code for that anatomic region. Documentation of less than the required elements requires the billing of the reason anyelement is non- The report should document the results of the evaluation of each element or the section. Each procedure code has specific required elements which are described in this The Obstetric ultrasound services may not be billed without image recording. Communication System(PACS). These images may be stored on film or in aPicture Archiving and reimbursable. output is considered part of the physical examination and is not separately

should be included in the patient’s medical record.

use of a hand-

one (1) limited exam may be billed per encounter.

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. All Rights Reserved. Rights All . healthcare eviCore Any follow CPT service. and detailed anatomic survey andare used onlywhen the study includes this CPT CPT ultrasound codes are used for transabdominal studies. CPT reportused to each additional fetus. CPT medical indication for ultrasound. the mother changes to a new medical caregiver at a new office and there is a C scan) performed during the second and third trimester CPT medical indication for ultrasound. the mother changes to a new medical caregiver at a new office and there is a CPT during the first trimester (< 14weeks). CPT ® PT 76816 is used to report follow upstudies requiring more information, such ® ® ® ® ® ® ® ® ® ® 76856, and CPT 76812is anadd- 76811 andCPT 76815 is used to report limited follow 76817 is used to report a transvaginal ultrasound. The other OB 76802, CPT 76805 andCPT 76805 andCPT 76801 andCPT 76801 andCPT

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® codes should be selected basedcriteria. on befollowing the selected should codes 76810, CPT ® ® ® ® ® ® on for each additional fetus. 78612 describe an extensive fetal ultrasound evaluation 76810 should only be used once per pregnancy unless 76810 are used to report complete studies (anatomy 76802 should only be used once per pregnancy unless 76802 are reported for complete studies performed 76857) if pregnancy has already been diagnosed. CPT obstetrical pelvic ultrasound procedure codes (CPT ®

Code Guidance Code ®

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 defined in CPT ______A      Ultrasound OB Trimester First for Elements Required OB-24.2: Guidelines Imaging 8 © 201 for ultrasound. Follow ultrasound. for changes mother ato new at caregiver a medical new and is athere office indication medical CPT 76801 to report additional each gestation. CPT CPT76801 and/or mayIt not be possible to placenta duringvisualize the the early of weeks pregnancy. CPT CPT indicates placental anatomic placental indicates structure could not be evaluated due to gestational age. complete first trimester transabdominal ultrasound (CPT Examination of maternal uterus and adnexa Qualitative assessment of amniotic fluid volume/gestational sac shape Survey visible of fetal anatomic structures and placental evaluation when possible Gestational sac/fetal measurements appropriate for gestation (< 14 weeks) Determinationof the ® ® ® ® 76815 76801 and CPT 76802 is an ‘add- . All Rights Reserved. Rights All . healthcare eviCore

as including the following elements: ® ® 76802 may still beappropriately the if report documentation billed - ® ® up studies to CPTup 76802 on’ reported code in conjunction with ‘primary CPT the procedure’ number of gestational sacs and fetuses should only be reported onceper only reported should be CPT ® ® ® Code Guidance Code 76801 and CPT

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Ultrasound OB Evaluation Anatomic TrimesterThirdFetal or Second for Elements Required OB-24.3: Guidelines Imaging 8 © 201 CPT A complete second or third trimester transabdominal ultrasound (CPT                                          

Femur length Femur Head, Head, and neckface, Lateral cerebralLateral ventricles; Choroid plexus;Choroid Midline falx; Midline Cavum septi pellucidi;Cavum septi Cerebellum; Cistern magna; and magna; Cistern Upper lip Upper the ofthe aneuploidy.risk ofA measurement the nuchal may behelpfulfold a during specific interval age assess to Stomach (presence, size, (presence, andStomach situs); Abdomen: outflow ventricular Right tract. outflow ventricular and Left tract; Four Chest/Heart Urinary bladder; Kidneys; Umbilical cord vesselUmbilical number. cord insertion site Umbilical into cord the and abdomen; fetal Spine: Cervical, thoracic, lumbar, andsacralCervical, spine. thoracic, Extremities: Legs andarms.Legs Genitalia: In andIn multiple whengestations medically indicated Placenta Location Appearance Relat Placental cordPlacental insertion (when possible) Standard evaluation Standard Fetal numberFetal Presentation Qualitative or or Qualitative semi of amnioticqualitative estimate fluid Cervix (transvaginal if cervical length is cervical if Cervix ≤ (transvaginal length Maternal anatomy Uterus Biometry Adnexa Head circumference diameter Biparietal ® . All Rights Reserved. Rights All . healthcare eviCore 76810) is defined in CPT - ionship to internal osionship to chamber view;

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 6. 5. ______7. 4. 3. 2. 1. R Guidelines Imaging 8 © 201 indication ultrasound. for Follow mother changes to a new medical caregiver at anew office and there is a medical coded as CPT CPT reporteach additional gestation. CPT eferences  

Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths a lengths cervical transvaginal serial of accuracy Predictive al. et JD, Iams MA, Elovitz MS, Esplin - 128(6):1459 2016; & Gynecology. Obstetrics Summary. 2016. Pregnancy, in Ultrasound 175. Bulletin Practice ACOG screening: importance of progesterone efficacy. efficacy. progesterone of importance screening: JAMA 2016;215(6) quan r s G t 544. Accessed November 15, 2017. http://onlinelibrary.wiley.com/doi/10.7863/ultra.15.03026/epdf 2017. 15, November Accessed 544. Jain S, Kilgore Edwards M, S, Kilgore Jain . et al , Stamilio David Berghella, Vincenzo Adeeb, Khalifeh high V Berghella H, Feltovich J, McIntosh Correlation H.J. Roh and H.J. Cho, - pre of prevention and Prediction 130 No. Bulletin Practice A en.pdf bronectin%20levels%20for%20spontaneous%20preterm%20birth%20among%20nulliparous%20wom %20serial%20transvaginal%20cervical%20lengths%20and%20quantitative%20vaginal%20fetal%20fi https://www.rtihs.org/sites/default/files/28462%20Hunter%202017%20Predictive%20accuracy%20of - 9378(16)30112 nd.42.aspx http://journals.lww.com/greenjournal/Citation/2012/10000/Practice_Bulletin_No__130___Prediction_a Journal of Ultrasound in Medicine. in Ultrasound of . Journal birth preterm predicting for sonography ransvaginal eaffirmed 2016. Accessed November 15, 2017. 15, November Accessed 2016. eaffirmed creening in preterm birth prevent birth preterm in creening - http://www.ajog.org/article/S0002 2017. 6, December ccessed ynecology Fetal weight estimate weight Fetal Abdominal circumference ® ® . All Rights Reserved. Rights All . healthcare eviCore - - 76805 andCPT 76810 is an ‘add titative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. nulliparous among birth preterm spontaneous for levels fibronectin fetal vaginal titative and low and - 2017:317(10):1047 . .

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- 739 - 2016;215(3):B2 - American Journal of Obstetrics of Journal American prevention. birth preterm for women risk ®

0/fulltext 76815CPT or 744. 1460. doi:10.1097/aog.0000000000001812 1460. ® - . on’ code used with the ‘primary procedure’ CPT 76810

1056. Accessed December 6, 2 6, December Accessed 1056. RK, et al. Revisiting the cost the Revisiting al. et RK, B7. Accessed November 15, 2017. 2017. 15, November Accessed B7.

s ® ion. 76816. hould only be used once per pregnancyper once onlyused hould be - cervical lengths measured by transabdominal a transabdominal by measured lengths cervical between

up studies to CPT ,

et al .The role of routine cervical length screening in selected screening length cervical routine of role .The al et American Journal of Obstetrics & Gynecology. Obstetrics of Journal American

A J Obstet Gynecol Obstet A J - effectiveness of universal cervical length cervical universal of effectiveness ® Obstetrics & Gynecology & Obstetrics birth. term Ultrasound approach for cervical lengt cervical for approach Ultrasound 017. 8924 8924 76805 and CPT - 9378(16)00215 - http://www.ajog.org/article/S0002 - Jul;215(1):101.e1 2016 .

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Ultrasound OB RequiredOB-Anatomic24.4: ElementsDetailed Fetalfor a Evaluation Guidelines Imaging 8 © 201 evaluation the of elements: following for CPT for CPT imaging). and Perinatologists, Radiologists Medicine specialists, should belimited to those with perform special skills to this study, assuch Maternal Fetal ofPerformance the specialized anatomic evaluation (CPTfetal                                       ®

76811 and CPT . All Rights Reserved. Rights All . healthcare eviCore Digits: numberDigits: andposition Head, Head, and neckface, 3rd ventricle 3rd 4th ventricle 4th Lateral ventricles Lateral Corpus callosum Corpus lobes,Cerebellar vermis, and Integrity andshapeIntegrity of cranial vault Brain parenchyma Brain Neck Palate, andPalate, maxilla, mandible, tong (nose/lips/lens face Coronal Profile Ear position and position Ear size Aortic arch Chest/Heart Orbits Superior andSuperior vena inferior cava Gallbladder glands Adrenal Small and large bowel Abdomen: Ribs ofIntegrity diaphragm Lungs 3- 3- Liver Renal arteries Spleen Integrity of wallIntegrity abdominal Integrity ofIntegrity spine andoverlying soft tissue Spine: Shape and curvature Extremities: Number: architectureNumber: and position Feet Hands ® ® 76805 andCPT vessel andtrachea view view vessel

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Guidelines Imaging 8 © 201  CPT  additional gestation. each                   

. All Rights Reserved. Rights All . healthcare eviCore NPI) isNPI) *Follow appropriate. Genitalia 76816 Adnexa at at centers referral tertiary with perinatology departments. studiesThese are at usually 18 performed 20to andareweeks oftenmost completed Only onemedically procedure indicated CPT Placenta Sex Masses Placental cordPlacental insertion placenta Accessory/succenturiate lobe with of location connecting vascular supply to primary Biometry Cerebellum Nasal bonemeasurement 22(15 to wk) Nuchal (16 thickness to 20 wk) andouterInner orbital diameters Maternal Anatomy Tibia/fibula Ulna/radius Humerus Uterus Cervi ® ® 76812 is an ‘add-

x (transvaginal if cervical length is ≤ 3.0cm

on’ used code with ‘primary CPT the procedure’

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______9. 8. 7. 6. 5. 4. 3. 2. Practice 1. References Guidelines Imaging 8 © 201 1460. Accessed November 3, 2017. 3, November Accessed 1460. 2012 s quan G K pr G Jain S, Kilgore M, Edwards, RK, et al. Revisiting the cost the Revisiting al. et RK, Edwards, M, Kilgore S, Jain JAMA a lengths cervical transvaginal serial of accuracy Predictive al. et JD, Iams MA, Elovitz MS, Esplin al. et D, Levine AZ, Abuhamad UM, Reddy 739. al. et Berghella, Vincenzo Adeeb, Khalifeh, high V, Berghella H, Feltovich J, McIntosh http://onlinelibrary.wiley.com/doi/10.7863/ultra.15.03026/epdf 2017. 15, November Accessed 544. birt preterm predicting for sonography transvaginal H.J. Roh, and H.J. Cho, Gynecol Obstet Pregnancy. in Ultrasound Summary: 175 No. Bulletin Practice A, son John H, Minkoff J, Wax Radiologists in Ul Radiologists an Obstetricians of College American Medicine, in Ultrasound of Institute American Medicine, Fetal en.pdf bronectin%20levels%20for%20spontaneous%20preterm%20birth%20among%20nulliparous%20wom %20serial%20transvaginal%20cervical%20lengths%20and%20quantitative%20vaginal%20fetal%20fi https://www.rtihs.org/sites/default/files/28462%20Hunter%202017%20Predictive%20accuracy%20of - 9378(16)30112 Ultrasound_in.50.aspx http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ - T5k4qdLfS6J8OlAGmAHfkKiXIDZdpW4U1 http://api.ning.com/files/cZ399qCqOaHeuZzVLVyhlBxiUetrbLyKO3Bw9Tt6vH2VZjNDiuNoRV*TfNUrq nd.42.aspx http://journals.lww.com/greenjournal/Citation/2012/10000/Practice_Bulletin_No__130___Prediction_a - http://www.ajog.org/article/S0002 2017. 6, December Accessed Medicine in Ultrasound of Journal qualifications. and components, indications, examination ultrasound creening: importance of progesterone efficacy. efficacy. progesterone of importance creening: ennedy Shriver National Institute Of Child Health and Human Development. Socie Development. Human and Health Child Of Institute National Shriver ennedy ynecology ynecologists, American College of Radiology, Society for Pediatric Radiology and Society of Society and Radiology Pediatric for Society Radiology, of College American ynecologists, prevention. prevention. birth eterm . All Rights Reserved. Rights All . healthcare eviCore - - titative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous women. nulliparous among birth preterm spontaneous for levels fibronectin fetal vaginal titative - ;120(4):964 and low and - 2017:317(10):1047 . . - pre of prevention and Prediction No.130: Bulletin . 2014; . . - 215(3):B2 2016; . - American Journal of Obstetrics of Journal American prevention. birth preterm for women risk

- 33(2):189 0/fulltext 973 op. Imaging Worksh Fetal trasound

reaffirmed 2016. reaffirmed .

Correlation Correlation . American Journal of Obstetrics & Gynecology Obstetrics of Journal American 195. Accessed November 15, 2017. 15, November Accessed 195. 1056. Accessed December 6, 2017. 6, December Accessed 1056. 2017. 2017. 15, November Accessed B7. et al. C al. et between cervical lengths measured by transabdominal and by transabdominal measured lengths cervical between onsensus report on detailed fetal anatomic ultrasound anatomic ultrasound anatomic fetal on detailed report onsensus et al. The role of routine cervical length screening in selected screening length cervical routine of role The al. et

Accessed November 15, 2017. 15, November Accessed

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Obstet Gynecol Obstet . 2014; Med. Ultrasound J Journal of Ultrasound in Medicine. in Ultrasound of Journal - effectiveness of universal cervical lengt cervical universal of effectiveness Obstetrics & Gynecology & . Obstetrics birth term 8924 8924 - 9378(16)00215 - http://www.ajog.org/article/S0002 - Jul;215(1):101.e1 2016 . . . D ec

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______FetalNuchalOB-24.5: Translucency Guidelines Imaging 8 © 201 1.   Director, Center for AdvancedTherapy for Center Fetal Director, Prof.Ob L.StevenMD, Warsof, Adaptedfrom                     

   pregnancy. hernia, anddiaphragmatic defects, syndromes ingenetic euploid current during fetuses) and bi is anincreasedthere risk aneuploidy, imaging for should bebased upon the MOM N for between 44and 83 millimeters); first The credentialed by thecredentialed Maternal Medicine Fetal or Foundation performing sonographer The the study and the physician the be study must interpreting CPT Follow Review (NTQR). Program 18,Trisomy andother disorders. genetic atspace backthe of neckthe fetal assess to risk Downfor (Trisomy Syndrome 21), CPT Measure the widest at space anduse of largest 3 technicallymeasurements correct Clear image Clear ofMargins NT edges are clear Angle of insonationAngle is perpendicular NTto Fetus in MidFetus plane Sagittal lines NT Clear Midsagittal viewMidsagittal spine of infetal seen cervical region & thoracic Tip of noseTip seen in fetal profile Should not seeShould not stomach ribs, or heart & Third seen ventricle fourth in CNS Fetus occupies majority of ima occupies of majority Fetus Image predominatelyImage by headneckfilled andfetal thorax The fetus The should occupyfetus 50%> of image Fetal headin Fetal neutral position Amniotic fluid Amniotic betweenseen fluid chin and chest Angle 90Angle < degrees Fetus observedFetus away amnion from Measurement Use the + calipers Place crosshairs onPlace crosshairs the edge, inner but not in the space clear Measurement is perpendicularMeasurement to long axis of the fetus

ochemical ochemical markers, >= 3.5 increased mm risk defects,cardiac abdominalfor wall 76813 76816 ( - up studies CPTup studies to ® ® trimester istrimester screening typically donebetween 11and 136/7 weeks (CR 76814 is -

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CPT an add

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76813 and CPT . . Gestational age approximately age Gestational is 11 13to 6/7 weeks.

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Follow and Limited OB-24.6: 1. References nuchal translucency screening (CPT and/or fetal indication, then the CPT (CPT and should not be routinely donewhenever anultrasound for nuchal translucency The use of ultrasound codes (CPT       Practice Note Guidelines Imaging 8 © 201 Required elements of the 76813 ultrasound code include: include: ultrasound code of 76813 elements the Required   P Society for Maternal and Fetal Medicine (SMFM), coding committee. SMFM Coding Committee Whit Committee Coding SMFM committee. coding (SMFM), Medicine and Fetal Maternal for Society documentation of ultrasound images. Written documentation of each c image to crown - Comparison of the largest nuchal translucency measurement from an acceptable bordersthe of fetal nuchaltranslucency At least three separate measurements of the largest distance between the inner between the outer edge of the nuchal skin and the amnion neutral position and spontaneous embryonic movement allows for differentiation Observation of the embryo at high magnification until the embryonic neck is in a Observation of fetal cardiac activity Fetal crown -       one or abnormalities more previously revealed onultrasound. CPT BPP(re: whichmodified is NST with CPT in listed elements the code i.e. “fetal definition, heartbeat”, placental location or checkfluid CPT aper: Billing of 76801 and/or 76813 with cfDNA . October 2017 . 2017 October . cfDNA with 76813 and/or 76801 of Billing aper: ®

CPT CPT CPT onlyReported once, ofregardless CPT service Modifier Modifier ® ®

76816 76815 ® ® ® ® ® ®

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rump measurement

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up ® ® ® ® or look” study“quick to used report oneor ofmore the Up Studies -Up omponentof the examination andpermanent 76801/ CPT 76810. 76810. ® ®

study designed to reassess fetal size re or 76801 code can indeed be billed along with the ® 76813/ CPT

® ® Code Guidance Code the numberthe of and onlyfetuses, per once date of 76816 and CPT

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______Doppler studies).The following parameters are evaluated: gestation. However, BPP may beutilized below 26weeks in cases of FGR (with Typically all components of the BPP, such as breathing, are not present until 26 weeks uterus). NOT be performed prior to the time when the fetus would bethe of viable outside risk of fetal death in the antenatal period (appropriately performed > 24 weeks; should and is designed to predict the presence or absence of fetal asphyxia and, ultimately the The BPP combines data from ultrasound imaging and fetal heart rate (FHR) monitoring BiophysicalOB- 24.8: (BPP) Profile ObstetricOB-Transvaginal24.7: Ultrasound Guidelines Imaging 8 © 201 depending ondepending payer policy. separately. BPP non and/or CPT76816, ultraso obstetrical Although 76819. non (Fetal non If CPT CPT CPT performto both studies at once. atperformed the same sitting and reported as two codes, there is rarely a indication medical anobstetricalAlthough transvaginal and ultrasound ultrasound transabdominal be can CPT CPT once. and reportedsitting as two is it necessary codes, not togenerally perform both studies at       

® ® ® ® ® ® ®

- Code Guidance Code 76817 76817 76819 does notinclude non the 76818 includes non- . All Rights Reserved. Rights All . healthcare eviCore Reactive FHR (non- Qualitative amniotic fluid volume, at least one vertical pocket 2 x 2cm Fetal tone Gross fetal body movements Fetal breathi stress is performedtesting without BPP, codethe appropriate useto is CPT

Each study must have aseparate images, interpretations and reports indicated to perform both studies at once. There are certain - stress test). CPT test). stress The use of use The - modifier ® is reported is reported only of regardless the once of number fetuses. is used to report anobstetrical ultrasound. transvaginal 76820) and BPP (CPT -

stress performed ontesting, more onethan should be fetus, reported

ng movements

stress testing. clinical circumstances in which it would be medically

und (CPT ® ® stress testing portion) 59025 should not be reported with CPT codes

59 on the second andsubsequent studies is appropriate, CPT ® ®

® 76818 and CPT

stress testing portion. codes: CPT ®

Code Guidance Code

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______   PracticeNotes OB-24.9 If BPP ≤ 6, repeat BPP in 24 hours Practice Note Guidelines Imaging 8 © 201    SGA/FGR fetus with normal umbilical artery Doppler. Doppler to time delivery in the near term artery Doppler is normal. Based on this evidence it is reasonable to use MCA useful test in SGA/FGR fetuses detected after 34weeks of gestation when umbilical acidosis at birth and should be used to time delivery. MCA Doppler may be a more m In the near 1.04 although MCA PI < – was not astatistically significant predictor of outcome on logistic regression, outcome in SGA/FGR neonates of less than 33 weeks gestational age (n = 604), it umbilical artery Doppler is abnormal. In the largest study of predictors of neonatal in preterm SGA/FGR fetuses have delivery. Most studies investigating MCA Doppler as a predictor of adverse outcome accuracy to predict acidaemia and adverse outcome; it should not be used to time theIn preterm SGA monochorionic twin pregnancies see Fet of Causes Isoimmunization/Other the assessmentofthe fetusrisk at anemia for Middle Cerebral Artery Doppler (MCA): Doppler flow studies of the MCA are used in    MCA Doppler (CPT MCA Doppler CPT CPT iddle cerebral artery Doppler (PI <5th centile) has moderate predictive value for

. All Rights Reserved. Rights All . healthcare eviCore – with AnemiaFetal of Causes Isoimmunization/Other preeclampsia, is andpredict stillbirth considered investigational. known discordant twins (See: gestation weeks known oligohydramnios acquired or con acquired and non- Rhesus polycythemia sequence anemia to isoimmunization/alloimmunization, Twin a as Performed amniocentesis substitute to evaluatefor a at fetus risk for due anemia Known twin s to twin transfusion; knownFGR; s for Utilized 1.21) and major morbidity (LR 1.12, 95% CI 1.1 ® ® :

76821 describes Doppler velocimetry of the 76820 Doppler Fetal Polyhydramnios -

term SGA/FGR fetus with normal umbilical artery Doppler, anabnormal immune hydrops caused by parvovirus B19 infection or any other known

describes Doppler velocimetry of the umbilical artery genital cause of fetal anemia. of cause fetal genital /FGR fetus, middle cerebral artery (MCA) Doppler has limited ® ® 76821), at starting 34weeks, if Doppler 2 SDs was associated with neonatal death (LR 1.12, 95% CI

See: ee: CPT

OB OB ® - ee: - - reported low predictive value, especiallywhen 8.1 4.1 16.1 Code Guidance Code : :

OB OB

Cerclage in Place in Current Pregnancy CerclageCurrent inPlace in Amniotic Fluid Abnormalities AmnioticFluid

al Anemia/Parvo/Hydrops al - Suspected multiple Pregnancies multipleSuspected term (34 weeks gestation or greater) - - 16.1 16.7

see: see: See See Suspected multiple Pregnancies Suspected multiple : Multiple: Pregnancies

middle cerebral artery. cerebral middle 8924 8924 OB

OB - 3.4 – - 1.33). 3.1 -

3: Alloimmunization/Rh 3: Fetal Hydrops AssociatedFetalHydrops

CPT Alloimmunization/RH ® ®

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______7. 6. 5. 4. 3. 2. 1. References Guidelines Imaging 8 © 201 http://onlinelibrary.wiley.com/doi/10.1002/uog.7738/pdf 1– 2011;37:19 1133. cerebral Doppler indices in late in indices Doppler cerebral pr I 2016 2016 - http://www.ajog.org/article/S0002 Gynecol and Obstet Practice Bulletin No. 134: No. Bulletin Practice & Gynecology Obstetrics pregnancy. in Ultrasound Summary: 175: No. Bulletin Practice & Gynecology. Obstetrics Surveillance. Fetal Antepartum 145: No. Bulletin Practice Oros D, Figueras F, Cruz elibrary.wiley.com/doi/10.1002/uog.13275/epdf http://onlin Gynecology RA, Filly UM, Reddy http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ h.45.aspx http://journals.lww.com/greenjournal/Abstract/2013/05000/Practice_Bulletin_No__134___Fetal_Growt Ultrasound_in.50.aspx Fetal.35.aspx http://journals.lww.com/greenjournal/Citation/2014/07000/Practice_Bulletin_No__145___Antepartum_ 4&type=abstract http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2008&issue=07000&article=0002 Velauthar L, Plana MN,Kalidindi M, et al. First practice. in obstetric studies flow Doppler artery Uterine EJ. AC, Hayes Sciscione andGynecology. Obstetrics maging. - ameta outcome: egnancy . All Rights Reserved. Rights All . healthcare eviCore - ;128(6):1459 2017. 15, November Accessed .

Accessed November 15, 2017. 15, November Accessed . . 2014; . . 5. 5.

Accessed November 15, 2017. 15, November Accessed . 1460. Accessed November 15, 2017. 15, November Accessed 1460. - 43(5):500 .

and - 2009;201(2):121 .

– Resonanc Magnetic and Ultrasonography Imaging: Prenatal JA. Copel Obstetrics & Gynecology Obstetrics Restriction. Grown Fetal Martinez R Martinez analysis involving 55 974 women. women. 55 974 involving analysis 507. Accessed November 16, 2017. 16, November Accessed 507. – onset small onset - 9378(09)00283

, - 2008;112:145 126. Accessed November 15, 2017. 15, November Accessed 126. et al. Longitudinal changes in uterine, umbilical and fetal and umbilical uterine, in changes Longitudinal al. et –

for - trimester uterine artery Doppler and advers and Doppler artery uterine trimester – gestational age fetuses. age fetuses. gestational X/fulltext 157. .

. Accessed November 14, 2017. 14, November Accessed . 8924 8924 Ultrasound in Obstetrics & in Obstetrics Ultrasound Ultrasound Obstet Gynecol Obstet Ultrasound

- 121(5):1122 2013; . American J of J American www.eviCore.com

2014, reaffirm 2014, Page 98of108

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______5. 4. 3. 2. 1. References    ArtDuplexOB- (Uterine24.10: Scan Guidelines Imaging 8 © 201 CPT study of only the arterial flow. complete study is not documented, for example, in the case of afollow CPT outflow vessels of one or more organs. This code is not used for obstetric imaging. evaluated in its entirety. A complete study involves the evaluation of the inflow and CPT http://onlinelibrary.wiley.com/doi/10.1002/uog.7738/pdf dysfunction. dysfunction. O N third - http://onlinelibrary.wiley.com/doi/10.1046/j.1469 2011;37:191 Severi FM, Bocchi C, Visentin A Visentin C, Bocchi FM, Severi Gynecol Obstet Ultrasound Doppler. artery umbilical normal with fetuses small in compromise of identification M, Geary JC, Kingdom R, Hershkovitz cer Oros D, Figueras F, Cruz CM Bilardo E, Cosmi AA, Baschat Gynecol. Obstet Ultrasound restriction? growth fetal term or A, Ghidini N, P, Roncaglia Vergani https://www.researchgate.net/publication/11466710_Uterine_and_fetal_cerebral_Doppler_predict_the 04&type=Fulltext http://journals.lww.com/greenjournal/Pages/articleviewer.aspx?year=2007&issue=02000&article=000 Director review beyond if 16 weeks gestation. One time only study CPT The gestation for patients with chronic hypertension or who are at risk for preeclampsia. of Uterine Artery Doppler evaluation is now justified when utilized before 16 weeks Treatment is now possible if started prior to 16 weeks gestation. Therefore, the use use of CPT screening). The Society Maternal of Fetal Medicine (SMFM) has recommended the Medicine Foundation (similar to certification process Nuchalfor Translucency technique, and abnormal test thresholds have been established by the Fetal hypertension, preeclampsia, and possibly FGR). Provider certification, study Aspirin therapy can be instituted to decrease the risk of adverse outcomes (chronic weeks. The clinical utility however is limited to the first trimester when low dose predict adverse outcomes when utilized in the first and second trimester, prior to 16 Uterine artery Duplex (Doppler) scan (CPT ovember 16, 2017. 2017. 16, ovember bstet Gynecol bstet ® ® ® ebral Doppler indices in late in indices Doppler ebral . All Rights Reserved. Rights All . healthcare eviCore

– 93976 93976 93975 trimester small trimester . 2000;15(3):209 ®

– Obstet Gynecol. Gynecol. Obstet code recommended by SMF describes alimited duplex scan and should be reported when a describes acomplete duplex scan and should be reported if an organ is is usedtoreport a ® 5.

93976 only. .

Accessed November 16, 2017. 16, November Accessed 8. Accessed November 15, 2017. 15, November Accessed –8. 2002;19:225 . – http://onlinelibrary.wile y.com/doi/10.1002/uog.7583/abstract http://onlinelibrary.wile for – – – gestational age fetuses with normal umbilical artery Doppler. Doppler. artery umbilical normal with fetuses age gestational 12. Accessed November 15, 2017. 15, November Accessed 12. Martinez R, et al. Longitudinal changes in uterine, umbilical and fetal and umbilical uterine, in changes Longitudinal al. et R, Martinez – 2007;109:253 – , onset small onset

et al. Uterine and fetal cerebral Doppler predict the outcome of outcome the predict Doppler cerebral fetal and Uterine al. et , et al. Can adverse neonatal outcome be predicted in late preterm late in bepredicted outcome neonatal adverse Can al. et et al. Predictors of neonatal outcome in early outcome neonatal of Predictors al. et fetal umbilical CPT et al. Fetal cerebral blood flow redistribution in late gestation: late in redistribution flow blood cerebral Fetal al. et ® Code Guidance Code – 61. Accessed November 16, 2017. 16, November Accessed 61.

for M is CPT M is – 0705.2000.00079.x/epdf gestational age fetuses. age fetuses. gestational ery) ® 93976), evaluation has been shown to - placental flow flow study placental

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______12. 11. 10. 9. 8. 7. 6. Guidelines Imaging 8 © 201 1133. Obstetrics andGynecology Obstetrics Imaging. U Practice Bulletin No. 134: No. Bulletin Practice http://onlinelibrary.wiley.com/doi/10.1002/uog.8863/epdf T Stampalija - http://www.ajog.org/article/S0002 Gynecol. Obstet practice. obstetric in studies flow Doppler artery Uterine SciscioneEJ. Hayes AC, and Resonance Magnetic and Ultrasonography Imaging: Prenatal JA. Copel and RA, Filly UM, Reddy estriction http://journals.lww.com/greenjournal/Abstract/2014/05000/A_Practical_Approach_to_Fetal_Growth_R Fetal.35.aspx http://journals.lww.com/greenjournal/Citation/2014/07000/Practice_Bulletin_No__145___Antepartum_ h.45.aspx http://journals.lww.com/greenjournal/Abstract/2013/05000/Practice_Bulletin_No__134___Fetal_Growt 4&type=abstract http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2008&issue=07000&article=0002 gestational_age_fetuses_with_normal_umbilical_artery_Doppler - _outcome_of_third http://onlinelibrary.wiley.com/doi/10.1002/uog.13275/epdf Gynecology Velauthar L, Plana MN, Kalidindi M, et al. First al. et M, Kalidindi MN, Plana L, Velauthar JA, Copel Surveillance. Fetal Antepartum 145: No. Bulletin Practice 2014 pr 2016 ltrasound Obstet Gynecol Obstet ltrasound - ameta outcome: egnancy . All Rights Reserved. Rights All . healthcare eviCore - ;124(1):182 ;

- 123(5):1057 Accessed November 15, 2017. 15, November Accessed .22.aspx . Obstetrics & Gynecology Obstetrics restriction. growth fetal to approach A practical MO. Bahtiyar and - 43(5):500 2014; . , . Alfirevic Z Alfirevic

. - 2009;201(2):121 192, . d November 16, 2017. 16, d November Accesse 1069. trimester_small

reaffirmed in 2016. Accessed November 15, 2017. 15, November Accessed in 2016. reaffirmed , Cochrane Reviews' summaries and their relevance for imaging for relevance andtheir summaries Reviews' Cochrane G. Gyte and

Obstetrics & Gynecology Obstetrics Restriction. Grown Fetal .

- 2010;36(6):779 analysis involving 55 974 women. women. 55 974 involving analysis 507. - 9378(09)00283 126.

- Accessed November 16, 2017. 16, November Accessed for . - 2008;112(1):145 -

Accessed November 15, 2017. 15, November Accessed 80. 80.

- trimester uterine artery Doppler and advers and Doppler artery uterine trimester Accessed November 15, 2017. 15, November Accessed X/fulltext 157. Accessed November 14, 2017. 14, November Accessed 157. .

. Obstetrics & Gynecology Obstetrics . 8924 8924 Ultrasound in Obstetrics & in Obstetrics Ultrasound .

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______1. Reference    measurement. Interval PR and arteriosus, of theductus Doppler venosus, ductus of the Doppler Practice Notes Echocardiography FetalOB- 24.11: Guidelines Imaging 8 © 201  procedures CPTprocedures CPT CPT wave displaycontinuous with spectral CPT without M or CPT separatelynot billable Suchoutput. heart tone is fetal monitoring partconsidered of the physical examination andis heart tonesfetal a using hand- is inappropriaIt . . reported Intervals PR and Arteriosus Ductus Venosus, Ductus are how and #1: When Tip Coding 2017 July Committee Coding SMFM evaluation, it is billed as 76827 then, and 76828 on subsequent studies. so it is billed as 76828. If performed as part of aninitial fetal echocardiogram PR interval measurement: evaluation, it is billed as 76827 then, and 76828 on subsequent studies. so it is billed as 76828. If performed as part of aninitial fetal echocardiogram Ductus arteriosus Doppler: Ductus Venosus Doppler is not billed when it is the sole assessment performed. echocardiogram study. Initial evaluation is reported as 76827; follow Doppler: venosus Ductus CPT    ® ® ® ®

93325 76828: is a follow upor Doppler repeat echocardiogram fetal 76827 describes a echocardiography, Doppler complete pulsedfetal, wave and/or 76825 describes real echocardiography, fetal time with documentation (2D), image with . All Rights Reserved. Rights All . healthcare eviCore should should never be billed with CPT follow a is ®

76826:

- is used to report color mapping in conjunction with fetal echocardiography within conjunction fetal mapping color used report to is mode recordingmode never be billed more than once on any date of service te to report codes CPT codes report to te

® ® 76825 - up or repeat fetal echocardiogram

– CPT held or any device Doppler does that not create a hard ® ® 76828. This is billable when sampled as part of a fetal This is often performed after another ultrasound study, This is often performed after another ultrasound study, CPT

76825 ® Code Guidance ®

76825

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______     and3DOB- 24.12:Rendering 4D Guidelines Imaging 8 © 201 positives. Fractional limb volume measurement eliminates this issue and decreases false this is the use of the fetal abdominal circumference to determine growth. 3D due small A second clinical scenario is seen with gastroschisis. Since the fetal abdomen is volume measurement of the humerus is required to evaluate FGR.for the femur length is vital in determination of fetal weight andgrowth. Fractional limb determination of fetal growthwhen there is absence of lower limbs / rs.femu Since, reasons that require 3D ultrasound when 2D cannot be utilized. Such as Clinical use of 3D ultrasound should be on an individual basis. There can be specific achieved with 2D US, remains to be established. however, its contribution to improving the accuracy of fetal scanning over rates authors concluded that 3D/4D US provides many advantages in fetal imaging; assessment, morphometry andvolumetry, as well as functional assessment. The applied to the study of the fetus. Fetal applications include all types of anatomical ultrasound application. The investigators and the challenges each organ system presents, versus the advantages of each varied. Their use in fetal medicine varies with the nature of the tissue to be imaged applications Yagel et al described the state of the science of 3D/4D ultrasound (3D/4D US) replacement for,2- dimensional ultrasonography may behelpful in diagnosis as an adjunct to, but not a facial anomalies, neural tube defects, and skeletal malformations where 3- prenatal diagnosis in advantages, proofof aclinical advantage 3- of traditionally inaccessible by 2- and m technical advantages of 3- Current guidelines on ultrasonography in pregnancy from ACOG state: "The 3D and 4D rendering in conjunction with ultrasound. There is currently insufficient data to generate . All Rights Reserved. Rights All . healthcare eviCore anipulate an infinite number of planes and to display ultrasound planes

to the defect present, there is artificially high rate of FGR. The cause of

in fetal medicine. They noted that 3D/4D US applications are many and

dimensional general is still lacking. Potential areas of promise include fetal dimensional ultrasonography include its ability to acquire dimensional ultrasonography. Despite these technical

ultrasonography.”

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______4. 3. 2. 1. References Guidelines Imaging 8 © 201 2017. I f https://www.medscape.com/medline/abstract/22343249 Gynecol Obstet Ab E, Merz 1460. & Gynecol. Obstet pregnancy. in Ultrasound Summary: 175 No. Bulletin Practice RA, Filly UM, Reddy Lee W Ultrasound_in.50.aspx http://journals.lww.com/greenjournal/Abstract/2016/12000/Practice_Bulletin_No__175_Summary___ 4&type=abstract http://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2008&issue=07000&article=0002 Obstetrics & Gynecology Obstetrics maging. Ultrasound Obstet Gyneco Obstet Ultrasound volume. limb ractional . All Rights Reserved. Rights All . healthcare eviCore

http://onlinelibrary.wiley.com/doi/10.1002/uog.11185/epdf Accessed November 3, 2017. 3, November Accessed , Deter R Deter

ramowicz JS. 3D/4D ultrasound in prenatal diagnosis: is it time for routine use? Clin use? routine for time it is diagnosis: prenatal in ultrasound 3D/4D JS. ramowicz

, . . Sangi ; 2012 Mar

and . - Haghpeykar H Haghpeykar

Copel JA. Prental Imaging. Imaging. Prental JA. Copel - 55(1):336 .

- 2008;112(1):145 51. Accessed November 16, 2017. 16, November Accessed 51. , et al.

Prospective validation of fetal weight estimation usi estimation weight fetal of validation Prospective

2013; 157. Accessed November 14, 2017. 14, November Accessed 157. Ultrasonography and Magnetic R Magnetic and Ultrasonography . 41 - (2):198 8924 8924 . 203. Accessed November 16, November Accessed 203.

- 2016;128(6):1459 www.eviCore.com Page 103of108 esonanc

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______ultrasound is equivocal and additional information is needed for counseling purposes Fetal MRI may beconsidered for surgical planning (re: fetal anomalies) and/or if an MRI fetal for Indications    FetalOB- 24.13: MRI Guidelines Imaging 8 © 201 twins monochorionic of Complications and pelvis retroperitoneal Abdomen, Thorax and neck face Skull, Spine Brain Fetal organs (CPT If onlyplacentaormater Do notreportCPT Fetal MRI(CPT CP

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nal pelvisismagedwithoutfetalmaging,useMRIpelvis Cases at risk for pulmonary hypoplasia secondary to oligohydramnios, oligohydramnios, to secondary hypoplasia pulmonary for risk at Cases effusion hernia; diaphragmatic congenital emphysema); lobar congenital and sequestration, malformation; adenomatoid (congen malformations airway pulmonary Congenital therapy postnatal and planning, delivery management, prenatal counseling, parental impact may that Conditions clefts Venolymphatic anomalies vertebral sirenomelia; agenesis; regression/sacral caudal teratomas; sacrococcygeal defects; tube Neural complications pregnancy twin infarctions; hydranencephaly; malformations; Vascular development cortical cerebral of malformations dysgenesis; callosal corpus sclerosis; tuberous E.g. development cortical cerebral of malformations anomalies; fossa posterior holoprosencephaly; dysgenesis; callosal corpus Ventriculomegaly; Indication sub category improved co amonochorionic of death after morbidity of assessment twins; of treatment laser to prior anatomy vascular of Delineation microcolon megacystis as such anomalies bowel and oligohydramnios; severe of in cases anomalies renal cloaca); (e.g. anomalies genitourinary complex masses); renal or and suprarenal teratomas, sacrococcygeal Abdominal skeletal or mass, chest ® 74713foreachadditionalges

delineation of anatomy in conjoined twins in conjoined anatomy of delineation –

® pelvic cyst.; tumors (e.g. hemangiomas, neuroblastomas, neuroblastomas, hemangiomas, (e.g. tumors cyst.; pelvic

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Obstetrical Ultrasound Imaging Guidelines - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______2. 1. References Guidelines Imaging 8 © 201 assessment surgery Fetal Fetal organs http://www.guidelines.gov/content.aspx?id=32509 Accessed November 16, 2017. 2017. 16, November Accessed P ( Kilcoyne A, Shenoy A, Kilcoyne imagi resonance magnetic fetal of performance optimal and safe the for guideline practice SPR - 5(5):507 2014; Research. Advanced of Journal A review. practice: to approach An MRI: Fetal SN. Saleem MRI). MRI). American Journal of Roentgenology. of Journal American Pitfalls. and Pearls Percreta: lacenta . All Rights Reserved. Rights All . healthcare eviCore American College of Radiology (ACR) Radiology of College American

523. ~AAmerican College of Radiology (ACR), Society for Pediatric Radiology (SPR). ACR (SPR). Radiology Pediatric for Society (ACR), Radiology of College ~AAmerican 523.

category Indication main

- Bhangle AS, Roberts DJ et al. MRI of placenta Accreta, Placenta Increta a Increta Placenta Accreta, placenta of MRI al. et DJ Roberts AS, Bhangle

http://www.ajronline.org/doi/pdf/10.2214/AJR.16.16281 Indication sub category masses. surgery; needing twins monochorionic of complications obstruction); airway high congenital or mass neck (e.g. airway the obstructing processes teratomas; sacrococcygeal Meningomyelocele;

; 2010:10. ; .

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Obstetrical Ultrasound Imaging Guidelines Imaging Guidelines V20.0.2018

OB-25: High Risk Medications and Substances Specific drugs that qualify as risk factors in High Risk Pregnancy and qualify as medical indications for Specialized Fetal Anatomic Scan (CPT® 76811): If another high risk indication see appropriate guideline for any further imaging.

High Risk Medications/Substances Alcohol Aminoglycosides (amikacin, gentamycin, kanamycin, tobramycin and other mycins) Amphetamines Angiotensin II antagonists or blockers Anti-neoplastics (cancer drugs) Accutane/isoretinoin/retinoic acid Aspirin – only if exposed less than 10 weeks gestation Atenolol ACE inhibitors (benzapril, captopril, enalopril, fosinopril, lisinipril, etc) Anticonvulsants (phenytoin, carbamazepine, valproate, primidone, phenobarbital, Dilantin) Azathioprine Benzodiazepines (Diazepam (valium), etc) Carbon monoxide Chlordiazepoxide Cocaine Codeine Cortisone Coumadin/ warfarin Cyclophosphamide Cytarabine Daunorubicin Dextroamphetamine Ergotamine Fluconazole (and other anti-fungals) Heparin Lithium Methimazole Methotrexate Methyl mercury Misoprostol Oral contraceptives Paramethadione Paroxitine/SSRI Penicillamine Primidone Progesterones (exposure less than 12 weeks) and anti-progesterone drug RU486 Pregabalin/lyrica

______© 2018 eviCore healthcare. All Rights Reserved. Page 106 of 108 400 Buckwalter Place Boulevard, Bluffton, SC 29910 (800) 918-8924 www.eviCore.com - 918 (800) 29910 SC Bluffton, Boulevard, Place Buckwalter 400 ______3. 2. 1. References Guidelines Imaging 8 © 201 Valproic acid Trimethadione Trifluroperazine Thalidomide Tetracyclines Substance abuse Selective serotonin reuptake inhibitors (SSRI) Retinoic Quinine http://journals.lww.com/greenjournal/pages/collectiondetails.aspx?TopicalCollectionID=37 - 111(4):1001 - http://www.jppt.org/doi/abs/10.5863/1551 2017. Ther Pharmacol Pediatr J Know. Should Pharmacist Lactation: and Pregnancy in Use Medication A. Evaluating Holmes, and B, Burkey, 2017. 16, November Accessed 2015. 22. January Benefit Improved Lactation: and Pregnancy in Drugs Medications Psychiatric of Use 92: No. Bulletin Practice 431132.pdf https://www.fda.gov/downloads/Drugs/DevelopmentApprovalProcess/SmallBusinessAssistance/UCM . All Rights Reserved. Rights All . healthcare eviCore

acid/retinoid medications

1020, Reaffirmed 2016. Accessed November 16, 2017. 16, November Accessed 2016. Reaffirmed 1020,

(heroin, methadone, subutex, cocaine)

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Termination ® 76801) and/or one transvaginal ultrasound

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