O42.10 — Premature rupture of membranes, onset of labor more than 24 hours following 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
- Determination of gestational age
- Assessment of fetal number (e.g., multiple gestation)
- Assessment of fetal viability
- Determination of placental location
- Other diagnostic obstetric indications when a specific clinical question needs to be answered
- One standard first-trimester ultrasound (CPT 76801) allowed per pregnancy.
1 Active Policy
AMBETTER-CP.MP.38 — Ultrasound in Pregnancy
Related Codes
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