CurrentColorado Rocky Mountain Health PlansPolicy N/A

Obstetric (OB) ultrasound reimbursement and limits

Defines UnitedHealthcare Community Plan Medicaid reimbursement policy for obstetric fetal ultrasound services billed on CMS-1500/UB04, including indications, code sets, limits per pregnancy, and when detailed anatomic exams are considered medically necessary or investigational.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyObstetric (OB) ultrasound reimbursement and limits

Policy CodePolicy N/A

Change TypeOperational updates to attachments and state exceptions (non‑clinical)

Effective DateN/A

Next Review DateN/A

Key ActionAllow first three OB ultrasounds per pregnancy; require high‑risk diagnosis code for fourth and subsequent scans unless state exception applies.

SourceLink

POLICY UPDATE CHANGES

Attachments Section: ICD-10-CM Standard and Limited (Routine) Fetal Ultrasound Diagnosis List updated multiple times between 2024 and 2026.

Attachments Section: ICD-10-CM Detailed and High Risk Fetal Ultrasound Diagnosis List updated on 10/5/2025 and 9/7/2025.

State Exceptions Section: Idaho added (11/16/2025) and New Mexico added (4/20/2025); California removed (7/13/2025); Washington updated (10/19/2025); Maryland added (8/4/2024) then removed (7/19/2024).

History Section: older entries prior to certain dates archived at multiple revision points.

first threeOB ultrasounds allowed per pregnancy (default)

76801–76819OB ultrasound CPT codes listed

18-20 weeks

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ACOG optimal gestational age

not coveredDetailed anatomic exam not covered for routine indications

severalState exceptions changed

Coverage Criteria for Obstetric Ultrasound

OB Ultrasound Coverage Criteria

Covered when ONE OR MORE of the following indications are present:

ANY of the following

To confirm cardiac activity
To confirm the presence of an intrauterine pregnancy
To evaluate a suspected ectopic pregnancy
To evaluate maternal pelvic or adnexal masses or uterine abnormalities
As an adjunct to procedures (amniocentesis, cervical cerclage placement, external cephalic version, chorionic villus sampling, embryo transfer, or localization/removal of an intrauterine device)
To assess for certain fetal anomalies in patients at high risk
Follow-up evaluation of a fetal anomaly
Determination of fetal presentation
Estimation of gestational age
Evaluation for abnormal biochemical markers
Evaluation for fetal well-being
Evaluation for premature rupture of membranes or premature labor
Evaluation in those with a history of previous congenital anomaly
Evaluation of abdominal or pelvic pain
Evaluation of cervical insufficiency
Evaluation of fetal condition in late prenatal registrants
Evaluation of fetal growth
Evaluation of suspected amniotic fluid abnormalities
Evaluation of suspected fetal death
Evaluation of suspected multiple gestation
Evaluation of suspected placental abruption
Evaluation of suspected uterine abnormality
Evaluation of vaginal bleeding
Examination for suspected hydatidiform mole
Follow-up evaluation of placental location for suspected placenta previa
Significant discrepancy between uterine size and clinical dates
To assess for findings that may increase the risk of aneuploidy

ALL of the following

Covered CPT codes include standard and detailed OB ultrasound codes (examples: 76801, 76802, 76805, 76810, 76811, 76812, 76815, 76816, 76819)
First three OB ultrasounds per pregnancy are allowed (see Limits and State Exceptions for rules that apply to additional scans)

ALL of the following

Use detailed anatomic fetal ultrasound (e.g., CPT 76811/76812) when there are known or suspected fetal anatomic abnormalities, including anatomic abnormalities due to genetic conditions
Use detailed anatomic fetal ultrasound for evaluation of amniotic band syndrome

ALL of the following

Detailed fetal anatomic examination is considered experimental/investigational for routine screening indications
Not covered for routine evaluation solely to determine fetal sex or to provide photographic images
Not covered solely because the pregnant woman is on bupropion (Wellbutrin) or smokes/uses cannabis without other indications
Multiple serial detailed fetal anatomic ultrasound examinations during pregnancy are not supported due to inadequate evidence of clinical utility

Detailed Anatomic Ultrasound (76811/76812) Policy

Detailed (targeted) fetal anatomic ultrasound (CPT 76811/76812) is covered only when specific high-risk or diagnostic indications are present; otherwise it is investigational.

ANY of the following

Known or suspected fetal anatomic abnormalities
Amniotic band syndrome (also called amniotic constriction band syndrome)
Anatomic abnormalities due to genetic conditions
Follow-up evaluation of a previously identified fetal anomaly

ALL of the following

Limits and State Exceptions

Per-pregnancy limits apply unless superseded by a specific state exception; place-of-service rules also apply.

ALL of the following

The first three OB ultrasounds per pregnancy are allowed
Claims for the fourth and subsequent OB ultrasound procedure per pregnancy must contain a high-risk pregnancy diagnosis code from the ICD-10-CM Detailed and High-Risk Fetal Ultrasound Diagnosis list unless a different state limit applies

ALL of the following

For POS 23, a fourth and/or subsequent OB ultrasound per pregnancy must contain either an OB pregnancy diagnosis code from the ICD-10-CM Pregnancy Fetal Ultrasound Diagnosis list or a high-risk pregnancy diagnosis code

ANY of the following

Coding and Diagnosis Lists

Covered CPT Codes - OB ultrasoundCPTCovered

76801	OB ultrasound - standard/limited/routine
76802	OB ultrasound - repeat or follow-up (routine)
76805	OB ultrasound - standard
76810	OB ultrasound - second trimester
76811	Detailed fetal anatomic ultrasound (targeted/detailed)
76812	Detailed fetal anatomic ultrasound, repeat/complete
76813	Obstetric ultrasound service code (listed in policy)
76814	Obstetric ultrasound service code (listed in policy)
76815	OB fetal biometry
76816	OB multiple gestation ultrasound

1–10 of 12

1/2

ICD-10-CM diagnosis lists (attachments)ICD-10

No codes listed

Per-pregnancy OB ultrasound limit — inv-06: Per-pregnancy OB ultrasound limit

Default allowed per pregnancyFirst three OB ultrasounds per pregnancy are allowed.

Requirement for fourth and subsequentClaims for the fourth and subsequent OB ultrasound procedure per pregnancy must contain a high‑risk pregnancy diagnosis code from the ICD‑10‑CM Detailed and High‑Risk Fetal Ultrasound Diagnosis list unless a different state limit applies.

Emergency department (POS 23) exceptionFor place of service 23, a fourth and subsequent OB ultrasound must contain either an OB pregnancy diagnosis code from the Pregnancy Fetal Ultrasound Diagnosis list or a high‑risk pregnancy diagnosis code.

State-specific variationsState limits may override the default; some states exempt the limit or have different numeric limits (see State Exceptions in attachments).

Attachment update frequency — inv-07: Attachment update frequency

Provider Actions, Billing and Authorization

Prior Authorization

OB ultrasound limits — fourth+ scans require high‑risk DX (and state-specific rules)

Allow first three OB ultrasounds per pregnancy; claims for the fourth and subsequent OB ultrasound procedures per pregnancy must include a high-risk pregnancy diagnosis code from the ICD-10-CM Detailed and High-Risk Fetal Ultrasound Diagnosis list unless a different state limit applies. For place of service 23 (emergency department), fourth and subsequent OB ultrasounds must contain either an OB pregnancy diagnosis code from the ICD-10-CM Pregnancy Fetal Ultrasound Diagnosis list or a high-risk pregnancy diagnosis code. Some states have exceptions or prior authorization requirements (for example, Texas requires prior authorization for >3 ultrasounds).

First three OB ultrasounds per pregnancy are allowed without additional diagnosis coding.
Fourth and subsequent OB ultrasounds require a high-risk pregnancy ICD-10-CM diagnosis code (unless state-specific limits differ).
For POS 23 (ED), fourth+ require either an OB pregnancy diagnosis code from the Pregnancy Fetal Ultrasound list or a high-risk pregnancy diagnosis code from the Detailed and High-Risk list.
Texas requires prior authorization for greater than 3 obstetrical ultrasounds per pregnancy; authorization is not required for ED/outpatient observation/inpatient settings (per state guidance).

Definitions and References

Standard Examination — inv-10: Standard Examination

DefinitionA Standard Examination includes evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, fetal number, plus an anatomic survey.

Essential anatomic elementsAbdomen (stomach, kidneys, bladder, umbilical cord insertion site, cord vessel number); chest (heart); extremities; head/face/neck (cerebellum, choroid plexus, cisterna magna, lateral ventricles, midline falx, cavum septi pellucidi, upper lip); spine.

Sex determinationSex is included when medically indicated in low‑risk pregnancies only for evaluation of multiple gestations.

Limited Examination — inv-11: Limited Examination

DefinitionA Limited Examination does not replace a standard examination and is performed to answer a specific question (e.g., confirm fetal heart activity with vaginal bleeding or establish presentation during labor).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyObstetric (OB) ultrasound reimbursement and limits

Policy CodePolicy N/A

Change TypeOperational updates to attachments and state exceptions (non‑clinical)

Effective DateN/A

Next Review DateN/A

Key ActionAllow first three OB ultrasounds per pregnancy; require high‑risk diagnosis code for fourth and subsequent scans unless state exception applies.

SourceLink

On This Page

SMFM and specialty guidance indicate detailed anatomic examinations are intended for suspected or known anomalies and are not routine for all pregnancies; performance is expected to be uncommon outside referral centers with specific expertise

A focused ultrasound assessment is appropriate for targeted reexamination of a specific organ/system or focused biometric assessment when follow-up is required

ALL of the following

Routine screening indications (i.e., as a substitute for standard screening)
Screening solely to determine fetal sex or to provide photographic images
Pregnant women on bupropion without other indications
Pregnant women who smoke or abuse cannabis without other indications
Multiple serial detailed anatomic ultrasounds during pregnancy without clear indication — inadequate evidence of clinical utility

ALL of the following

Use the detailed and high-risk ICD-10-CM diagnosis list when documenting medical necessity for detailed anatomic ultrasound when required by limits/policy

Some states are exempt from the OB ultrasound limit (examples include Arizona, Hawaii, Idaho, Kansas, Massachusetts, New Mexico)

Some states have different numeric limits (examples: Kentucky and Michigan limit to 2 OB ultrasounds)

Texas: prior authorization is required for greater than 3 OB ultrasounds per pregnancy; authorization is not required for ED/outpatient observation/inpatient settings

Washington: limited to 2 ultrasounds unless there is a high-risk diagnosis; any ultrasound with a high-risk diagnosis does not count toward the limit of 2

Certain states (e.g., Michigan, Missouri) permit additional detailed fetal ultrasound diagnosis codes for third and subsequent ultrasounds per their state rules

ALL of the following

When requesting payment for a fourth or subsequent OB ultrasound, include the appropriate high-risk ICD-10-CM diagnosis code or follow the applicable state-specific prior authorization process and diagnosis list as required

Update windowICD‑10‑CM diagnosis list attachments were updated multiple times between 2024 and 2026.

Recent update datesNotable attachment updates occurred on 8/4/2024; 10/20/2024; 4/13/2025; 4/20/2025; 7/13/2025; 9/7/2025; 10/5/2025; 10/19/2025; 11/16/2025; 11/23/2025; 12/14/2025; 1/25/2026; 2/8/2026.

Types of attachments changedAttachments updated include the ICD‑10‑CM Standard and Limited (Routine) Fetal Ultrasound Diagnosis List and the ICD‑10‑CM Detailed and High‑Risk Fetal Ultrasound Diagnosis List.

State exceptions activityState Exceptions section was modified across the period (examples: Maryland added 8/4/2024 then removed 7/19/2024; New Mexico added 4/20/2025; Idaho added 11/16/2025; California removed 7/13/2025; Washington updated 10/19/2025).

Documentation Required

Updated ICD-10 attachments and state exception changes

Attachment ICD-10-CM diagnosis lists for standard, limited (routine), detailed, and high‑risk fetal ultrasound have been updated multiple times between 2024 and 2026; state exceptions were also added, removed, or updated (examples include Idaho and New Mexico added, California removed, Washington updated, Maryland added then removed).

Attachments: Standard and Limited (Routine) fetal ultrasound diagnosis list updated on 2/8/2026, 1/25/2026, 12/14/2025, 11/23/2025, 10/19/2025 and earlier dates.
Attachments: Detailed and High Risk fetal ultrasound diagnosis list updated on 10/5/2025 and 9/7/2025.
State Exceptions: Idaho added (11/16/2025); New Mexico added (4/20/2025); California removed (7/13/2025); Washington updated (10/19/2025); Maryland added (8/4/2024) then removed (7/19/2024).

Typical usesMay be performed in first trimester to evaluate interval growth, estimate amniotic fluid volume, evaluate the cervix, or assess presence of cardiac activity.

ScopeFocused on a targeted clinical question and not a complete anatomic survey.

Detailed/Specialized Examination — inv-12: Detailed/Specialized Examination

DefinitionA Detailed/Specialized (targeted) Examination is performed when an anomaly is suspected based on history, laboratory abnormalities, or results of a limited or standard exam; it may include additional modalities (Doppler, fetal echocardiography, biophysical profile) and is performed by an operator with expertise.

IndicationsUsed for suspected fetal anomalies, amniotic band syndrome, or anatomic abnormalities due to genetic conditions; not indicated for routine screening alone.

Operator requirementsPerformed by an operator with experience and expertise who determines exam components on a case‑by‑case basis.

References — inv-13: References

Major guideline sourcesACOG Practice Bulletins on Ultrasonography in Pregnancy (Practice Bulletin No. 98 and No. 101) and related ACOG committee opinions.

Additional clinical studiesSelected studies cited include Chen et al. (Prenat Diagn. 2008/2009) on detailed morphology and first‑trimester measurements, and Kurjak et al. on 4D sonography in high‑risk pregnancies.

Policy revision historyReferences section documents policy version changes and attachment updates dated 2012 through 2026; see listed revision dates for attachment and state‑exception updates.