O42.00 — Premature rupture of membranes, onset of labor within 24 hours of rupture, unspecified weeks of gestation
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clear clinical indication and the specific diagnostic question for the ultrasound
- Documentation of ultrasound findings relevant to the indication (e.g., gestational age, fetal number, viability, placental location)
- Clinical documentation of history, laboratory abnormalities, or clinical examination supporting suspected anomaly.
- Documentation of suspicious findings from a limited or standard ultrasound when 76811 is performed for follow-up.
Key Coverage Criteria
- Suspected fetal death;
- Assess amniotic fluid volume in post-term gestation.
- Evaluate a pelvic mass that has been detected clinically.
- Maternity ultrasound is consideredmedically necessaryforanyof the following:
- Routine anatomy screen and dating:One ultrasound of a pregnant uterus per member, per routine course of care;Estimate gestational age for individuals with uncertain clinical dates.
- One ultrasound of a pregnant uterus per member, per routine course of care;
2 Active Policies
AMBETTER-CP.MP.38 — Ultrasound in Pregnancy
ANTHEM-CG-RAD-26 — CG-RAD-26 Maternity Ultrasound in the Outpatient Setting
Related Codes
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