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ICD-10-CM O03.9, Complete or unspecified spontaneous abortion without complication | No Prior Auth

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`O03.9`, Complete or unspecified spontaneous abortion without complication

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Clear clinical indication and the specific diagnostic question for the ultrasound
Documentation of ultrasound findings relevant to the indication (e.g., gestational age, fetal number, viability, placental location)
Clinical documentation of history, laboratory abnormalities, or clinical examination supporting suspected anomaly.
Documentation of suspicious findings from a limited or standard ultrasound when 76811 is performed for follow-up.

Key Coverage Criteria

Suspected fetal death;
Assess amniotic fluid volume in post-term gestation.
Evaluate a pelvic mass that has been detected clinically.
Maternity ultrasound is consideredmedically necessaryforanyof the following:
Routine anatomy screen and dating:One ultrasound of a pregnant uterus per member, per routine course of care;Estimate gestational age for individuals with uncertain clinical dates.
One ultrasound of a pregnant uterus per member, per routine course of care;

2 Active Policies

ANTHEM-CG-RAD-26, Maternity Ultrasound in the Outpatient Setting

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

Related Codes

76817(2 policies)A92.5(2 policies)76816(2 policies)76805(2 policies)76801(2 policies)76811(2 policies)76815(2 policies)O00.91(2 policies)

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When a second detailed anatomic ultrasound is performed, documentation that a new MFM group assumed care or that a second opinion was required.

Billing must include an appropriate high-risk diagnosis code as specified in Table 4.