Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesObstetrics/GynecologyAmbetter Georgia ultrasound coverage update | Open…
    Ask Trek AI about this page
    CurrentAmbetter GeorgiaPolicy WA.CP.MP.38

    Ultrasound in Pregnancy (Clinical Policy)

    Customize your policy alerts

    Sign up for Ambetter Georgia Policy WA.CP.MP.38 alerts

    Get alerted when Policy WA.CP.MP.38 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Medical necessity criteria and coding guidance for ultrasound use during pregnancy for Ambetter Georgia members and providers rendering obstetric imaging.

    Policy Summary
    PayerAmbetter Georgia
    PolicyUltrasound in Pregnancy (Clinical Policy)
    Policy CodePolicy WA.CP.MP.38
    Change TypeNo material changes
    Effective DateJun 1, 2026
    Next Review DateN/A
    Key ActionBill one detailed anatomic ultrasound (CPT 76811) per pregnancy with an appropriate high‑risk ICD-10 diagnosis code; include a supporting ICD-10 code on claims to demonstrate medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1detailed anatomic ultrasound allowed per pregnancy (76811)
    1standard first trimester ultrasound (76801)
    1standard second trimester ultrasound (76805)
    up to 13transvaginal ultrasounds allowed

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Not covered
    3D/4D ultrasounds
    20+distinct ICD-10 code ranges listed

    Coverage Criteria for Ultrasound in Pregnancy

    Medically Necessary Ultrasound Categories and Limits

    Covered when ALL of the following are met (per item):

    Standard first trimester ultrasound: One standard first trimester ultrasound (CPT 76801) allowed per pregnancy to establish viability, gestational age, and determine singleton vs multiple; subsequent standard first trimester ultrasounds are considered not medically necessary when a limited or follow-up ultrasound (CPT 76815 or 76816) would suffice.1 per pregnancy

    Use CPT 76817 for transvaginal first trimester exams

    Standard second trimester ultrasound: One standard second trimester ultrasound (CPT 76805) allowed per pregnancy for fetal morphology; subsequent standard second or third trimester ultrasounds are considered not medically necessary when a limited or follow-up ultrasound (CPT 76815 or 76816) would suffice.1 per pregnancy
    Detailed anatomic ultrasound: One detailed anatomic ultrasound (CPT 76811) allowed per pregnancy when performed to evaluate suspected anomaly based on history, laboratory abnormalities, clinical evaluation, or suspicious results from a limited or standard ultrasound; this exam must be billed with an appropriate high‑risk diagnosis code.1 per pregnancy (second allowed only for change of MFM practice, second opinion, or transfer to tertiary care)

    Further detailed anatomic ultrasounds beyond the one allowed per pregnancy are considered not medically necessary except as noted.

    Transvaginal ultrasound (TVU): Transvaginal ultrasound is medically necessary when conducted in the first trimester for the same indications as a standard first trimester ultrasound, and later to assess cervical length, placenta location in placenta previa, or after an inconclusive transabdominal ultrasound; cervical length screening frequency follows the Berghella approach.up to 13 per pregnancy

    Table 1 provides screening frequency guidance

    Diagnosis-based coverage condition

    Covered when an appropriate supporting ICD-10-CM diagnosis from the listed ranges is documented

    Supporting diagnosis: Member has any one of the listed ICD-10-CM diagnosis codes or ranges (for example O24.*, O26.*, O28.*, O29.* series) that support medical necessity for a first detailed fetal ultrasound.n>=1

    Codes and ranges are listed in the Coding Implications section.

    Coverage for First Detailed Fetal Ultrasound

    Covered when a listed ICD-10 diagnosis code supporting medical necessity is present:

    Diagnosis present: Any one of the ICD-10 codes or code ranges listed in this section appears on the claim and corresponds to the clinical indication (examples include uterine size‑date discrepancy, spotting, cervical shortening, abnormal antenatal screening, pregnancy‑related organ disorders, complications of anesthesia, or multiple gestation).1

    Use the specific code from the Coding Implications lists on the claim.

    Supported Diagnoses

    Covered when the submitted claim for a first detailed fetal ultrasound is accompanied by one of the following ICD-10 diagnosis codes:

    Presence of listed ICD-10 diagnosis: At least one of the ICD-10 diagnosis codes or code ranges shown in the policy’s Coding Implications section must be present on the claim to support medical necessity for the first detailed fetal ultrasound.

    See ICD-10 Codes Supporting Medical Necessity groups for exact codes and ranges.

    Medically necessary indications (diagnosis-based)

    Covered when an appropriate supporting ICD-10 diagnosis listed in this section is present

    Supporting diagnosis: Presence of any ICD-10 code or code range listed in this section that corresponds to pregnancy complications or specific indications (for example multiple gestation, uterine size‑date discrepancy, spotting, cervical shortening, abnormal antenatal screening, complications of anesthesia).N/A

    Document the specific listed code on the claim or authorization.

    Diagnosis-supported coverage

    First detailed fetal ultrasound is supported when an applicable ICD-10 diagnosis from the listed categories is present

    Supported diagnosis categories: Presence of any listed ICD-10 diagnosis code from categories such as multiple gestation (O30.x, O31.x), complications of pregnancy (O29.x), or continuing pregnancy after fetal loss/reduction (O31.*) supports medical necessity for a first detailed fetal ultrasound.any

    Document and bill with one of the listed ICD-10 codes.

    Diagnosis-based coverage criteria

    Covered when the claim includes one of the following ICD-10 diagnosis codes or ranges supporting medical necessity for a first detailed fetal ultrasound

    Diagnosis code match: Presence of any ICD-10 code or code within the listed ranges (examples include O29.x, O30.x, O31.x series) on the claim supports medical necessity for the first detailed fetal ultrasound.

    Use the most specific applicable code from the Coding Implications section.

    Medical necessity supported by diagnosis codes

    Covered when ANY of the following ICD-10 diagnosis codes or ranges are present on the claim to support medical necessity for the first detailed fetal ultrasound

    Supported diagnosis code present: Presence of any ICD-10 code or code range listed in the policy (see Coding Implications: O29.*, O30.*, O31.*, O35.*, O36.*, O40.*–O42.*, O41.* and related ranges) supports medical necessity for the first detailed fetal ultrasound.

    Refer to the Coding section for full lists and ranges.

    Medical necessity — diagnosis code requirement

    Covered when the claim includes an ICD-10-CM diagnosis code from the listed ranges that corresponds to the clinical indication for the first detailed fetal ultrasound.

    Required: Claim must include a diagnosis code from the policy's listed ICD-10-CM codes or ranges that support medical necessity for a first detailed fetal ultrasound.

    The policy supplies extensive ICD-10 ranges (O30*, O31*, O32*, O35*, O36*, O40*–O42*, O41*, etc.); include the most specific applicable code.

    Diagnosis-supported coverage

    Covered when a listed ICD-10 diagnosis supporting fetal or placental pathology is present on the claim

    Supporting diagnosis present: Presence of any one of the listed ICD-10 codes or ranges related to fetal or placental pathology (examples include O40.1xx–O40.9xx, O41.00x–O41.03x, O41.8X20–O41.8X39, O42.00–O42.919, O43.012–O43.129, O36.8390–O36.8399) supports medical necessity for a first detailed fetal ultrasound.any

    Provider should code the most specific applicable ICD-10 code from the Coding Implications lists.

    Supporting diagnosis requirement

    Covered when ALL of the following are met

    Diagnosis requirement: A first detailed fetal ultrasound is supported when the claim includes an ICD-10 diagnosis code listed in the policy's Coding Implications (for example O42.*, O43.*, O41.8X3* ranges for rupture of membranes and placental disorders) and the medical record documents the corresponding clinical indication.

    Include the most specific subcode applicable; absence of a listed supporting diagnosis may result in denial.

    The policy identifies several services that are not medically necessary. Specifically, 3D and 4D ultrasound imaging (e.g., CPT 76376, 76377) are considered not medically necessary because available evidence does not show these modalities improve management or outcomes compared with two‑dimensional ultrasound. Ultrasound exams performed solely to determine fetal sex or to provide parents with fetal photographs are also not medically necessary. In addition, growth scans performed less than 2 weeks apart, ultrasound used only to confirm pregnancy without other clinical indications, and routine first‑trimester follow‑up ultrasounds in the absence of pain or bleeding are listed as potential denial triggers and considered not medically necessary.

    The policy permits only a single comprehensive detailed fetal anatomic ultrasound (CPT 76811) per pregnancy except in limited extenuating circumstances; therefore, further detailed anatomic ultrasounds beyond that first allowed examination are considered not medically necessary unless justified by circumstances such as change of maternal‑fetal medicine (MFM) practice, a documented second opinion, or transfer to tertiary care. Claims for additional 76811 exams without an applicable exception may be subject to coding review or denial.

    Coding Guidance and Supported Codes

    Covered CPT CodesCPTCovered
    76801Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 day), transabdominal approach; single or first
    76805Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (≥14 weeks 0 day), transabdominal approach; single or first gestation
    76811Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation
    76815Ultrasound, pregnant uterus, real time with image documentation, limited, 1 or more fetuses
    76816Ultrasound, pregnant uterus, real time with image documentation, follow-up, transabdominal approach, per fetus
    76817Ultrasound, pregnant uterus, real time with image documentation, transvaginal
    Not Medically Necessary CPT/Imaging Codes (3D/4D)CPTNot Covered
    763763D rendering with interpretation and reporting requiring concurrent supervision; not requiring image post-processing on an independent workstation
    763773D rendering with interpretation and reporting requiring image post-processing on an independent workstation
    Example ICD-10 codes supporting medical necessity for detailed ultrasound (incomplete list)ICD-10
    A92.5Zika virus disease
    B06.00Rubella
    B50.0Malaria
    B97.6Parvovirus as the cause of diseases classified elsewhere
    D56.0Thalassemia
    D57.00Sickle-cell disorders
    E66.01Morbid (severe) obesity due to excess calories
    M32.0Systemic lupus erythematosus (SLE)
    N18.9Chronic kidney disease, unspecified
    O00.01Abdominal pregnancy with intrauterine pregnancy
    ICD-10-CM codes that support medical necessity for first detailed fetal ultrasoundICD-10Covered
    O24.011 - O24.019Diabetes mellitus in pregnancy (code range listed)
    O24.111 - O24.119Diabetes mellitus in pregnancy (code range listed)
    O24.311 - O24.319Diabetes mellitus in pregnancy (code range listed)
    O24.414 - O24.415Diabetes mellitus in pregnancy (code range listed)
    O24.811 - O24.819Diabetes mellitus in pregnancy (code range listed)
    O24.911 - O24.919Diabetes mellitus in pregnancy (code range listed)
    O26.20Pregnancy care for patient with recurrent pregnancy loss / retained IUD referenced in context
    O26.22 - O26.23Pregnancy care codes (ranges listed)
    O26.30, O26.32 - O26.33Pregnancy care codes (ranges listed)
    O26.40, O26.42 - O26.43Pregnancy care codes (ranges listed)
    1–10 of 17
    1/2
    ICD-10 Diagnosis Codes that Support Medical Necessity for First Detailed Fetal UltrasoundICD-10Covered
    O26.33
    O26.40
    O26.42
    O26.43
    O26.612
    O26.613
    O26.614
    O26.615
    O26.616
    O26.617
    1–10 of 99
    1/10
    ICD-10 Codes Supporting Medical Necessity for First Detailed Fetal UltrasoundICD-10Covered
    O26.43Other specified pregnancy-related conditions (listed in document)
    O26.612Liver and biliary tract disorders in pregnancy (specific code listed)
    O26.619Liver and biliary tract disorders in pregnancy, unspecified
    O26.832Pregnancy related renal disease (specific code listed)
    O26.839Pregnancy related renal disease, unspecified
    O26.843Uterine size-date discrepancy (listed range)
    O26.849Uterine size-date discrepancy, unspecified
    O26.852Spotting complicating pregnancy (listed range)
    O26.859Spotting complicating pregnancy, unspecified
    O26.872Cervical shortening (listed range)
    1–10 of 33
    1/4
    ICD-10 codes supporting medical necessity (extracted items and ranges shown individually where present)ICD-10Covered
    O29.029
    O29.112
    O29.119
    O29.122
    O29.129
    O29.212
    O29.219
    O29.292
    O29.299
    O30.001
    1–10 of 38
    1/4
    ICD-10 Diagnosis Codes supporting medical necessity for First Detailed Fetal UltrasoundICD-10
    O26.852 - O26.859Spotting complicating pregnancy
    O26.872 - O26.879Cervical shortening / spotting complicating pregnancy (listed in various chunks)
    O28.3Abnormal findings on antenatal screening of mother / cervical shortening (listed)
    O28.5Abnormal findings on antenatal screening of mother (listed)
    O28.8Other specified abnormalities of amniotic fluid and membranes / antenatal findings (listed)
    O28.9Other and unspecified abnormal findings on antenatal screening of mother
    O29.012 - O29.019Abnormal findings on antenatal screening of mother (O29.01x series listed)
    O29.022 - O29.029Abnormal findings on antenatal screening of mother (O29.02x series listed)
    O29.112 - O29.119Abnormal findings on antenatal screening of mother (O29.11x series listed)
    O29.122 - O29.129Abnormal findings on antenatal screening of mother (O29.12x series listed)
    1–10 of 20
    1/2
    ICD-10 Diagnosis Codes that Support Medical Necessity for First Detailed Fetal UltrasoundICD-10Covered
    O29.012 - O29.019Complications of anesthesia during pregnancy (range shown in document)
    O29.022 - O29.029Complications of anesthesia during pregnancy (range shown in document)
    O29.112 - O29.119Complications of anesthesia during pregnancy (range shown in document)
    O29.122 - O29.129Complications of anesthesia during pregnancy (range shown in document)
    O29.212 - O29.219Complications of anesthesia during pregnancy (range shown in document)
    O29.292 - O29.299Complications of anesthesia during pregnancy (range shown in document)
    O30.001 - O30.099Twin pregnancy (range includes multiple specific twin pregnancy codes)
    O30.101 - O30.199Triplet pregnancy (range includes multiple specific triplet pregnancy codes)
    O30.201 - O30.299Quadruplet pregnancy (range includes multiple specific codes)
    O30.801 - O30.899Other specified multiple gestation
    1–10 of 15
    1/2
    ICD-10 codes listed as supporting medical necessity for first detailed fetal ultrasoundICD-10Covered
    O29.022
    O29.023
    O29.024
    O29.025
    O29.026
    O29.027
    O29.028
    O29.029
    O29.112
    O29.119
    1–10 of 37
    1/4
    ICD-10 Diagnosis Codes supporting medical necessity - multiple gestation and related pregnancy complications (grouped/ranges as presented)ICD-10
    O29.112 - O29.119
    O29.122 - O29.129
    O29.212 - O29.219
    O29.292 - O29.299
    O30.001 - O30.099Twin pregnancy (range includes twin pregnancy codes)
    O30.101 - O30.199Triplet pregnancy (range)
    O30.201 - O30.299Quadruplet pregnancy (range)
    O30.801 - O30.899Other specified multiple gestation
    O30.90, O30.92 - O30.93Multiple gestation, unspecified
    O31.10X0 - O31.23X9Continuing pregnancy after spontaneous abortion / intrauterine death of one fetus or more
    1–10 of 15
    1/2
    ICD-10 Diagnosis Codes that Support Medical Necessity for First Detailed Fetal UltrasoundICD-10Covered
    O29.122 - O29.129Maternal complications of pregnancy (range shown in document)
    O29.212 - O29.219Maternal complications of pregnancy (range shown in document)
    O29.292 - O29.299Maternal complications of pregnancy (range shown in document)
    O30.001 - O30.099Early pregnancy codes / multiple gestation (range shown in document)
    O30.101 - O30.199Twin pregnancy / triplet pregnancy ranges (document lists these ranges)
    O30.201 - O30.299Triplet pregnancy / higher-order multiple gestation ranges
    O30.801 - O30.899Multiple gestation, other/unspecified ranges
    O30.90Multiple gestation, unspecified
    O30.92 - O30.93Multiple gestation related codes
    O31.10X0 - O31.23X9Complications of multiple gestation of one fetus or more (range formatting per document)
    1–10 of 16
    1/2
    ICD-10 Diagnosis Codes that Support Medical Necessity for First Detailed Fetal UltrasoundICD-10
    O29.212 - O29.219
    O29.292 - O29.299
    O30.001 - O30.099
    O30.101 - O30.199Twin pregnancy range included
    O30.201 - O30.299Triplet pregnancy range included
    O30.801 - O30.899Quadruplet pregnancy range included
    O30.90
    O30.92 - O30.93
    O31.10X0 - O31.23X9
    O31.30X1 - O31.30X9
    1–10 of 16
    1/2
    ICD-10 Diagnosis Codes that Support Medical Necessity for First Detailed Fetal UltrasoundICD-10Covered
    O29.292 - O29.299O29.292 - O29.299 (listed range)
    O30.001 - O30.099O30.001 - O30.099 (listed range)
    O30.101 - O30.199O30.101 - O30.199 (listed range)
    O30.201 - O30.299O30.201 - O30.299 (listed range)
    O30.801 - O30.899O30.801 - O30.899 (listed range)
    O30.90O30.90 (listed)
    O30.92 - O30.93O30.92 - O30.93 (listed range)
    O31.10X0 - O31.23X9O31.10X0 - O31.23X9 (listed range)
    O31.30X1 - O31.30X9O31.30X1 - O31.30X9 (listed range)
    O31.32X0 - O31.32X9O31.32X0 - O31.32X9 (listed range)
    1–10 of 17
    1/2
    ICD-10 codes and ranges listed (partial extract)ICD-10Covered
    O29.292 - O29.299Maternal care codes listed in document (range)
    O30.001 - O30.099Multiple gestation codes (twin, triplet etc.)
    O30.101 - O30.199Multiple gestation codes
    O30.201 - O30.299Multiple gestation codes
    O30.801 - O30.899Multiple gestation codes
    O30.90, O30.92 - O30.93Multiple gestation/unspecified
    O31.10X0 - O31.23X9Maternal care related to placenta and multiple pregnancy complications (range)
    O31.30X1 - O31.30X9Maternal care codes (range)
    O31.32X0 - O31.32X9Maternal care codes (range)
    O31.33X0 - O31.33X9Maternal care codes (range)
    1–10 of 14
    1/2
    Additional ICD-10 codes and ranges (maternal care for suspected fetal conditions, amniotic fluid disorders, isoimmunization, decreased fetal movement, etc.)ICD-10Covered
    O34.02 - O34.03Maternal care for cervical incompetence and related conditions
    O34.30, O34.32 - O34.33Maternal care for unspecified congenital malformation of uterus / cervical incompetence
    O35.00X0 - O35.99X9Maternal care for suspected fetal abnormalities by organ system (multiple ranges)
    O35.AXX0 - O35.AXX9Maternal care for fetal facial anomalies (examples)
    O35.BXX0 - O35.BXX9Maternal care for fetal cardiac anomalies (range)
    O35.CXX0 - O35.CXX9Maternal care for fetal pulmonary anomalies (range)
    O35.DXX0 - O35.DXX9Maternal care for fetal gastrointestinal anomalies (range)
    O35.EXX0 - O35.EXX9Maternal care for fetal genitourinary anomalies (range)
    O35.FXX0 - O35.FXX9Maternal care for fetal musculoskeletal anomalies (range)
    O36.011 - O36.099, O36.111 - O36.199, O36.20X0 - O36.20X9Isoimmunization, hydrops fetalis, and related maternal care codes
    1–10 of 19
    1/2
    ICD-10 Codes supporting medical necessity (examples and ranges)ICD-10Covered
    O41.8X20 - O41.8X29Other specified disorders of amniotic fluid and membranes (code range as listed)
    O41.8X30 - O41.8X39Other specified disorders of amniotic fluid and membranes (alternate range shown)
    O42.00Premature rupture of membranes, unspecified as to onset details (listed)
    O42.012 - O42.02Premature rupture of membranes code range as listed
    O42.10Premature rupture of membranes — onset of labor within 24 hours / more than 24 hours (listed)
    O42.112 - O42.119Premature rupture of membranes code range as listed
    Additional ICD-10 code ranges referencedICD-10Covered
    O40.1xx+ - O40.9xx+Polyhydramnios / related amniotic fluid disorder codes (range shown)
    O41.00x+ - O41.03x+Other specified obstetric conditions (range shown)
    O36.8390 - O36.8399Placental transfusion syndromes (range shown)
    Placental and membrane-related ICD-10 codesICD-10Covered
    O42.912 - O42.919Preterm premature rupture of membranes / related (range)
    O43.012 - O43.019Placental transfusion syndromes (range)
    O43.112 - O43.119Malformation of placenta (range)
    O43.122 - O43.129Malformation of placenta (additional range)
    Repeated/overlapping code rangesICD-10
    O41.8X30 - O41.8X39Other specified disorders of amniotic fluid and membranes (repeat range)
    ICD-10 codes supporting medical necessity for first detailed fetal ultrasoundICD-10
    O41.8X30 - O41.8X39Other specified disorders of amniotic fluid and membranes / Malformation of placenta / related placental codes as listed
    O42.00Premature rupture of membranes, onset of labor within 24 hours of rupture
    O42.012 - O42.02Premature rupture of membranes, onset of labor within 24 hours of rupture (range and related subcodes listed)
    O42.10Premature rupture of membranes, onset of labor more than 24 hours following rupture
    O42.112 - O42.119Premature rupture of membranes, onset of labor more than 24 hours following rupture (range)
    O42.912 - O42.919Preterm premature rupture of membranes, unspecified as to length of time between rupture and onset of labor
    O43.012 - O43.019Placental transfusion syndromes (range of subcodes)
    O43.022 - O43.029Placental transfusion syndromes (additional ranges)
    O43.112 - O43.119Placental transfusion syndromes (additional ranges)
    O43.122 - O43.129Malformation of placenta (range)
    1–10 of 15
    1/2
    None specified
    Policy identifierWA.CP.MP.38 (Ultrasound in Pregnancy)
    Actionable requirementOne detailed anatomic ultrasound (CPT 76811) is allowed once per pregnancy when performed to evaluate suspected fetal anomaly and must be billed with an appropriate high‑risk ICD‑10 diagnosis from the listed ranges.
    Documentation

    Provider Actions — Documentation, Billing, and Authorization

    Prior Authorization

    Limit and billing requirement for CPT 76811

    One detailed anatomic ultrasound (CPT 76811) is allowed once per pregnancy when performed to evaluate suspected anomaly and must be billed with an appropriate high‑risk diagnosis code; a second 76811 is only allowed for change of MFM group, a second opinion, or transfer to a tertiary care center.

    • Limit: 1 per pregnancy (second allowed only for new MFM practice, second opinion, or transfer to tertiary care).
    • Must be billed with an appropriate high‑risk ICD‑10 diagnosis code from the policy list.
    Documentation Required

    Use listed ICD‑10 codes to support medical necessity

    Claims for a first detailed fetal ultrasound must be supported by one of the ICD‑10‑CM diagnosis codes or ranges listed in the policy's coding sections (examples and extensive O-series ranges are provided).

    Definitions and Test Descriptions

    Background

    Ultrasound is the primary fetal imaging modality for assessing gestational age, fetal number, viability, and placental location. The policy emphasizes using ultrasound only when clinically indicated and choosing the timing and approach that answers the specific clinical question. Standard exams include a first‑trimester ultrasound (CPT 76801) for early dating and viability assessment, a second/third‑trimester ultrasound (CPT 76805) for routine fetal assessment after 14 weeks, and a detailed anatomic ultrasound (CPT 76811) when there is increased risk of anomaly based on history, laboratory results, or prior imaging. Transvaginal ultrasound (CPT 76817) is appropriate in the first trimester for similar indications or later for evaluation of cervical length or placenta location; based on the Berghella approach, up to 13 TVUs per pregnancy may be allowed for cervical length surveillance when indicated. Routine screening in low‑risk populations has not been shown to improve perinatal outcomes, so documentation of the specific clinical indication (and appropriate ICD‑10 diagnosis when billing for a detailed anatomic exam) is required to support medical necessity.

    Policy Summary
    PayerAmbetter Georgia
    PolicyUltrasound in Pregnancy (Clinical Policy)
    Policy CodePolicy WA.CP.MP.38
    Change TypeNo material changes
    Effective DateJun 1, 2026
    Next Review DateN/A
    Key ActionBill one detailed anatomic ultrasound (CPT 76811) per pregnancy with an appropriate high‑risk ICD-10 diagnosis code; include a supporting ICD-10 code on claims to demonstrate medical necessity.
    SourceLink
    On This Page
    Coverage Criteria for Ultrasound in PregnancyCoding Guidance and Supported CodesProvider Actions — Documentation, Billing, and AuthorizationDefinitions and Test DescriptionsBackground
    Include an appropriate supporting ICD‑10‑CM diagnosis code from the policy lists (examples: O30.*, O31.*, O32.*, O35.*, O36.*, O40*‑O42*, O41.*) on the claim to demonstrate medical necessity.
    Not medically necessary3D/4D ultrasounds (CPT 76376, 76377), ultrasounds solely to determine fetal sex or provide fetal photographs, and additional detailed anatomic ultrasounds beyond the one allowed per pregnancy absent extenuating circumstances are considered not medically necessary.
    DefinitionsFirst detailed fetal ultrasound = initial comprehensive sonographic fetal anatomic evaluation; follow‑up exams should use appropriate focused codes (e.g., 76816, 76805) when indicated.
  1. Use a specific code or code range from the policy (e.g., O24.*, O26.*, O28.*, O29.*, O30.*, O31.*, O32.*, O35.*, O36.*, O40*‑O42*, O41.*) that corresponds to the clinical indication.
  2. The coding module includes many listed ranges—select the most specific applicable code.
    3. Prior Authorization

    Authorization requests should cite a listed ICD‑10 code

    The policy does not specify a separate prior authorization process in these excerpts; when requesting authorization or submitting claims, include an appropriate ICD‑10 diagnosis code from the policy's lists to justify the service.

    • Prior authorization determinations will reference the documented ICD‑10 diagnosis codes that support medical necessity.
    • If authorization is sought, include one of the listed supporting diagnosis codes.
    Billing Rule

    Include a supported ICD‑10 diagnosis on claims

    Submit one of the ICD‑10 diagnosis codes or code ranges listed in the policy on the claim to substantiate medical necessity for the first detailed fetal ultrasound.

    • Examples of listed codes include multiple gestation codes (O30.* series), complications codes (O29.*), continuing pregnancy after loss (O31.*), amniotic fluid/placental codes (O40*‑O43*), and others shown in the coding sections.
    • Claims lacking an applicable listed code may be subject to coding review or denial.
    Documentation Required

    Document and submit a supporting ICD‑10 diagnosis

    Include an appropriate supporting ICD‑10 diagnosis from the policy's listed codes or ranges when submitting either prior authorization requests or claims for the first detailed fetal ultrasound to demonstrate medical necessity.

    • Document the specific listed ICD‑10 code in the medical record and on the claim.
    • If multiple overlapping ranges apply, code the most specific applicable diagnosis.
    Prior Authorization

    No prior‑auth rule stated; include diagnosis to support coverage

    The provided document segments do not state a separate prior authorization requirement for the first detailed fetal ultrasound; however, billing must include a supporting ICD‑10 diagnosis from the policy list to establish medical necessity.

    • No explicit PA process is specified in these excerpts.
    • Ensure claims include a listed ICD‑10 code to avoid coverage issues.
    Note

    Prior authorization not specified in excerpt

    No prior authorization instructions are specified in this excerpt; follow standard billing practice and include an appropriate listed ICD‑10 diagnosis to support the clinical indication.

    • If seeking authorization, reference the ICD‑10 codes/ranges presented in the coding sections.
    • Absence of a supporting listed diagnosis on the claim may result in denial.
    Prior Authorization

    Cite listed ICD‑10 codes for authorization/coverage requests

    When requesting authorization or documenting the service, use one of the ICD‑10 diagnosis codes or ranges listed in the policy's coding sections as the supporting diagnosis for a first detailed fetal ultrasound.

    • The policy lists multiple O‑series ranges (e.g., O29.*, O30.*, O31.*) that commonly support medical necessity for 76811.
    • Include the most specific applicable code when submitting requests.
    Prior Authorization

    Include a listed ICD‑10 code on authorization requests

    Prior authorization requests should include one of the ICD‑10 diagnosis codes or ranges shown in the policy so the requestor can justify the medical necessity of the first detailed fetal ultrasound.

    • Examples of code groups include multiple gestation (O30.*, O31.*), complications of anesthesia (O29.*), and placental/amniotic disorders (O40*‑O43*).
    • Providing the specific listed code expedites review and supports coverage.
    Prior Authorization

    Authorization determinations reference listed ICD‑10 codes

    Prior authorization reviewers will reference the documented ICD‑10 diagnosis code(s) from the policy's lists when evaluating medical necessity for a first detailed fetal ultrasound.

    • Document the applicable listed ICD‑10 code in the medical record and on the authorization/claim.
    • Use the most specific code from the O‑series ranges provided.
    Billing Rule

    Use listed ICD‑10 codes for authorization and claims

    Use an appropriate ICD‑10 diagnosis code from the policy's listed ranges when requesting authorization or submitting a claim for the first detailed fetal ultrasound to substantiate medical necessity.

    • The coding sections include multiple O30‑O32 and O31 family ranges for multiple gestation and other pregnancy complications—select the specific code that applies.
    • Claims without an applicable listed diagnosis may not meet coding implications for medical necessity.
    Denial Risk

    Include a listed ICD‑10 diagnosis to avoid denial

    The coding sections present extensive ICD‑10 code lists that support medical necessity; include one of these codes on the claim or authorization to justify a first detailed fetal ultrasound—absence of a listed supporting diagnosis may risk denial.

    • Policy examples include O30.*, O31.*, O32.*, O35.*, O36.*, O40*‑O42*, O41.*, and placental/membrane codes such as O41.8X3*, O42.*, O43.*.
    • Select and document the most specific applicable code from the lists.
    Billing Rule

    Diagnosis code required on claim to establish medical necessity

    Claims for a first detailed fetal ultrasound should include a supporting ICD‑10 diagnosis from the policy list (for example O42.*, O43.*, O41.8X3*); submitting without such a code may result in denial.

    • Ensure the medical record documents the specific listed ICD‑10 code that justifies the exam.
    • If no listed supporting diagnosis is present, the service may be considered not medically necessary.
    Step Therapy

    Use 76816 or 76805 for follow‑up, not repeat 76811

    For follow‑up of a detailed anatomic exam, bill the appropriate follow‑up CPT rather than repeating 76811—use CPT 76816 for a focused reassessment or CPT 76805 for fetal/maternal evaluation when indicated.

    • Do not repeat CPT 76811 for routine follow‑up; use 76816 for focused reassessment or 76805 for broader fetal maternal evaluation.
    • This aligns with Society of Maternal Fetal Medicine guidance cited in the policy.
    Note
    Note
    Documentation Required

    Document clinical indication and exam details

    Ultrasound exams should be performed only when indicated and must be appropriately documented, including the time and type chosen to answer specific clinical questions.

    • Document the clinical indication that corresponds to one of the listed ICD‑10 diagnosis codes.
    • Record exam type (e.g., 76811, 76805, 76816) and rationale in the medical record.
    Denial Risk

    Risk of denial if no listed supporting ICD‑10 code or inappropriate indication

    Claims lacking one of the ICD‑10 diagnosis codes listed as supporting medical necessity for the first detailed fetal ultrasound may be denied; ensure the claim includes a listed supporting diagnosis.

    • Potential denial triggers include services performed solely to determine fetal sex, provide fetal photographs, growth scans <2 weeks apart, ultrasound to confirm pregnancy without other indications, or unsupported follow‑up first‑trimester scans.
    • If the submitted diagnosis does not match any listed supporting codes, expect coding review or denial.
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note
    Note