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ICD-10-CM O12.00, Gestational edema, unspecified trimester | No Prior Auth

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`O12.00`, Gestational edema, unspecified trimester

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

Determination of gestational age
Assessment of fetal number (e.g., multiple gestation)
Assessment of fetal viability
Determination of placental location
Other diagnostic obstetric indications when a specific clinical question needs to be answered
One standard first-trimester ultrasound (CPT 76801) allowed per pregnancy.

1 Active Policy

AMBETTER-CP.MP.38, Ultrasound in Pregnancy

Related Codes

76377(1 policies)76801(1 policies)76805(1 policies)76811(1 policies)76815(1 policies)76816(1 policies)76817(1 policies)76376(1 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.