Z03.71 — Encounter for suspected problem with amniotic cavity and membrane ruled out
ICD-10-CM
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- When relevant to interpretation of no-call results: documentation of fetal fraction/genomic equivalents and relevant maternal factors (e.g., maternal weight) and sample handling/transport records (sample compromise was cited as affecting results).
- Documentation of receipt (or non-receipt) of a second maternal blood sample when one is requested following an initial no call.
- Newborn outcomes obtained from parent survey responses or provider reports (used in study outcome ascertainment).
- Molecular testing results when available for affected cases (study noted molecular testing completed for affected CF and SMA cases either as part of NBS or clinical indication).
Key Coverage Criteria
- Coverage of the above CPT codes is conditional: “CPT codes covered if selection criteria are met.”
- Alpha-fetoprotein (AFP); amniotic fluid (CPT 82106)
- Estriol (CPT 82677)
- Gonadotropin, chorionic (hCG); quantitative (CPT 84702)
- Gonadotropin, chorionic (hCG); qualitative (CPT 84703)
- Gonadotropin, chorionic (hCG) free beta chain (CPT 84704)
4 Active Policies
AETNA-CPB-0464 — Serum and Urine Marker Screening for Fetal Aneuploidy
ANTHEM-RAD.00038 — RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
ANTHEM-CG-LAB-27 — CG-LAB-27 Human Chorionic Gonadotropin Testing
ANTHEM-CG-LAB-26 — CG-LAB-26 Outpatient Alpha-Fetoprotein Testing
Related Codes
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