Obstetric (OB) ultrasound reimbursement
Defines UnitedHealthcare Community Plan Medicaid coverage, coding, limits, and medical necessity criteria for obstetric ultrasounds billed on CMS-1500/UB04 forms for network and non-network providers.
Attachments Section: ICD-10-CM Standard and Limited (Routine) Fetal Ultrasound Diagnosis List updated.
Attachments Section: ICD-10-CM Detailed and High Risk Fetal Ultrasound Diagnosis List updated.
State Exceptions Section: Idaho added; Washington and New Mexico updated; California removed; Maryland added then removed.
History Section: Entries prior to specific cutoff dates were archived on several occasions.
Coverage and Medical Necessity Criteria
Coverage criteria
Covered when the following clinical indications and medical necessity criteria are met:
ALL of the following
Detailed fetal anatomic ultrasound (CPT 76811, 76812) is medically necessary when ONE of the following is present:
- Evaluation for amniotic band syndrome (also known as amniotic constriction band syndrome).
- Known or suspected fetal anatomic abnormalities, including anatomic abnormalities due to genetic conditions.
- Detailed fetal anatomic ultrasound is not considered medically necessary for routine screening of normal pregnancy or solely to determine fetal sex or provide keepsake images.
- There is inadequate evidence to support multiple serial detailed fetal anatomic ultrasound examinations during pregnancy for routine indications; repeated detailed scans are not routinely supported.
Standard or Limited OB ultrasound (codes: 76801, 76802, 76805, 76810, 76815, 76816) are covered for indications including, but not limited to:
- 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 such as 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 or for follow-up evaluation of a fetal anomaly.
- Determination of fetal presentation and estimation of gestational age.
- Evaluation for abnormal biochemical markers, fetal well-being, premature rupture of membranes or preterm labor, history of previous congenital anomaly, fetal growth, suspected multiple gestation, placental abruption, uterine abnormality, vaginal bleeding, suspected hydatidiform mole, and follow-up evaluation of placental location for suspected placenta previa.
- Assessment when there is significant discrepancy between uterine size and dates, or to assess findings that may increase the risk of aneuploidy.
- When no specific indication exists, ACOG recommends performing an anomaly–screening obstetric ultrasound optimally between 18 - 20 weeks of gestation; earlier or later imaging may have technical limitations and should be documented.
- Focused ultrasound assessment is acceptable for reexamination of a specific organ or system known or suspected to be abnormal, or for focused assessment of fetal size (e.g., BPD, AC, femur length).
- For non-obstetric gynecologic conditions (e.g., fibroids), use non-pregnancy abdominal/pelvic ultrasound codes rather than pregnancy-related ultrasound codes.
CPT/ICD-10 Coding, Limits, and Attachments
| 76801 | Fetal and pelvic ultrasound, pregnant uterus, real time with image documentation; transabdominal approach, single or first gestation |
| 76802 | Each additional gestation |
| 76805 | Fetal and pelvic ultrasound, pregnant uterus, real time with image documentation; limited (e.g., fetal heart, placenta, fetal position, amniotic fluid volume) |
| 76810 | Fetal and pelvic ultrasound, pregnant uterus, real time with image documentation; complete (complete fetal and maternal anatomic survey) |
| 76811 | Fetal ultrasound, real time with image documentation, limited or follow-up |
| 76812 | Fetal ultrasound, real time with image documentation, detailed (complete fetal anatomic survey) |
| 76813 | Fetal biophysical profile |
| 76814 | Fetal biophysical profile with non-stress test |
| 76815 | Biophysical profile, re-evaluation |
| 76816 | Transvaginal fetal and pelvic ultrasound |
Provider Billing, Prior Authorization, and State Exceptions
OB Ultrasound Limits and Billing Requirements
UnitedHealthcare Community Plan Medicaid allows the first three OB ultrasounds per pregnancy. OB ultrasound CPT codes include: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, and 76819. Unless a different limit is outlined by the state, claims for the fourth and subsequent OB ultrasound procedure per pregnancy require a high‑risk pregnancy diagnosis code from the ICD‑10‑CM Detailed and High‑Risk Fetal Ultrasound Diagnosis list. For place of service 23 (emergency department), a fourth and subsequent OB ultrasound 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 from the ICD‑10‑CM Detailed and High‑Risk Fetal Ultrasound Diagnosis list.
- Affected CPT codes: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76819
- Fourth and subsequent OB ultrasounds require an ICD‑10‑CM high‑risk diagnosis code unless state rules differ
- Place of service 23 requires either an OB pregnancy diagnosis code or a high‑risk diagnosis for fourth+ ultrasounds
Attachments and State Exceptions Updates
State exceptions and attachments have been updated. See the ICD‑10‑CM diagnosis list attachments for the current Standard/Limited (Routine) and Detailed/High‑Risk fetal ultrasound diagnosis codes. State-specific variations include limits, exemptions, or additional allowable diagnosis codes; examples from recent updates: Massachusetts and New Mexico are exempt from the OB ultrasound limit; Michigan, Missouri, and Washington have modified limits or allow additional detailed fetal diagnosis codes; Texas requires prior authorization for >3 obstetrical ultrasounds except in ED, observation, or inpatient settings. Review the Attachments and State Exceptions sections for the full, up‑to‑date lists and any state-specific billing or prior authorization requirements.
- Attachments updated: ICD‑10‑CM Standard/Limited (Routine) and Detailed/High‑Risk Fetal Ultrasound Diagnosis lists — latest updates documented (see revision history)
- State Exceptions updated: adds/removals and state-specific rules (e.g., MA and NM exemptions; MI and MO additional allowable codes; TX prior authorization for >3 ultrasounds with ED/inpatient/observation exceptions; WA limits with high‑risk exceptions)
- Providers must consult the Attachments and State Exceptions sections when billing fourth and subsequent OB ultrasounds to ensure correct diagnosis coding, place-of-service handling, and prior authorization compliance
Examination Definitions and References
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