Obstetrical Ultrasounds
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Defines medical necessity, frequency, documentation, and reimbursement considerations for obstetrical ultrasound examinations for CareSource Georgia members; applies to providers submitting claims to CareSource Georgia.
No material clinical or coverage changes in this revision.
Obstetrical Ultrasound Coverage Criteria
Obstetrical ultrasound coverage criteria
Covered when ALL of the following are met:
ALL of the following
- Ultrasound must have a specific valid medical indication
- Medical record documentation must support the medical need for the ultrasound
- Timing, frequency, and type of ultrasound are determined by the medical indication; use of 3‑D/4‑D ultrasound requires appropriate documentation
- For healthy, asymptomatic, low‑risk singleton pregnancy (eg, maternal age under 35, no maternal comorbidities, single gestation, normal screening tests, no prior adverse outcomes): up to 2 total ultrasounds per pregnancy (including the standard ultrasound)
- CareSource may request documentation to validate medical necessity and accurate claims submission; appropriate and complete documentation must be presented at the time of review
Exclusions (Not medically necessary)
- Nonmedical use (e.g., determine fetal sex; provide parents with a view, video, and/or photograph of the fetus)
- Growth evaluation performed less than 2 weeks apart
- Follow‑up or re‑evaluation ultrasound in asymptomatic patients
Notes
- Reimbursement is determined at claim processing and depends on submission of approved HCPCS and CPT codes with appropriate modifiers; provider contract governs if conflict exists
- Additional ultrasounds beyond routine are supported when clinical indications arise (e.g., abnormal findings, maternal comorbidities, fetal growth concerns) per professional practice and documentation
Routine limit summary
- Routine ultrasounds for uncomplicated singleton pregnancy: up to 2 total during the pregnancy
CPT / HCPCS Guidance and Routine Limits
| No codes listed |
Documentation, Prior Review, and Reimbursement Instructions
Documentation request / prior review
CareSource may request documentation to support medical necessity and accurate claims submission; appropriate and complete documentation must be presented at the time of review to validate medical necessity. Providers should be prepared to supply medical record evidence that the ultrasound had a specific valid medical indication and that timing, frequency, and type of exam were supported by the clinical record.
- Medical record documentation must support the medical need for the ultrasound.
- Use of 3-dimensional and 4-dimensional ultrasound techniques require appropriate documentation.
- Appropriate and complete documentation must be presented at the time of review to validate medical necessity.
Claims submission and reimbursement requirements
Reimbursement is determined at claim processing and is dependent on submitting approved HCPCS and CPT codes along with appropriate modifiers; providers must submit the correct codes and modifiers and may be limited by claim review and contractual terms.
- Reimbursement will be established based upon a review of the actual services provided to a member and will be determined when the claim is received for processing.
- Reimbursement is dependent on, but not limited to, submitting approved HCPCS and CPT® codes along with appropriate modifiers, if applicable.
- If this policy conflicts with a provider's contract, the provider's contract governs.
Terminology and Exam Type Definitions
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