OB Ultrasound Authorization and Coding Guide Ultrasound Limited, follow-up transabdominal and...
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Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015 1
OB Ultrasound Authorization and Coding Guide
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OB Ultrasound Authorization and
Coding Guide
Horizon NJ Health OB Ultrasound Authorization and Coding Guide – November 2015 2
OB Ultrasound Authorization and Coding Guide
Table 1: CPT® Codes for routine ultrasounds
CPT Code US Description Covered by GEMS* Authorization
76801 OB US < 14 weeks single fetus GEMS2
76802 OB US < 14 weeks additional fetus GEMS2
76813 OB US nuchal measurement 1 gestation GEMS2
76814 OB US nuchal measurement add-on GEMS2
76805 OB US ≥ 14 weeks single fetus GEMS3
76810 OB US ≥ 14 weeks addl fetus GEMS3
76817 Transvaginal US ObstetricalGEMS2 (only 1 use in 1st Trimester [ < 14 weeks])
Table 2: Prior Authorization Requirement for Frequently Used Ultrasounds
CPT Code US Description Pre-Authorization Required
76811 OB US detailed single fetus Yes
76812 OB US detailed additional fetus Yes
76815 OB US limited fetus(s) Yes
76816 OB US follow-up per fetus Yes
76817 Transvaginal US ObstetricalYes if prior TVS was performed or greater than 14 weeks gestation
76818 Fetal bpp with non-stress testing Yes
76819 Fetal bpp without non-stress testing Yes
76820 Doppler velocimetry, fetal; umbilical artery Yes
76821Doppler velocimetry, fetal; middle cerebral artery
Yes
76825Echocardiography, fetal, cardiovascular system, initial
Yes
76826Echocardiography, fetal, cardiovascular system, follow up
Yes
76827 Doppler echocardiography, initial Yes
76828 Doppler echocardiography, follow up Yes
93325Doppler echocardiography color flow velocity
Yes
59000-76946 Amniocentesis-OB U/S Guided Yes
* GEMS stands for “Getting Early Maternity Services”
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A. Indications for a Detailed, Limited and Follow-up UltrasoundLimited, follow-up transabdominal and transvaginal obstetric ultrasounds will be approved for fetal, obstetrical or maternal complications.
B. Indications for Biophysical ProfileA biophysical profile is indicated when an appropriate, approved medical condition is present.
C. Indications for a Vessel DopplerSpecialty vessel doppler ultrasounds are indicated when an appropriate, approved medical condition is present. Vessel doppler exams are expected to be used infrequently for selected clinical scenarios and performed by clinicians with specialized expertise in the performance and interpretation of the study (refer to Table 3.)
D. Indications for Fetal EchoAccording to the 2010 AIUM’s practice guideline on Performance of Fetal Echocardiography, “indications for fetal echocardiography are often based on a variety of parental and fetal risk factors for congenital heart disease. However, most cases are not associated with known risk factors.” Common indications for a detailed scan of the fetal heart include, but are not limited to, the conditions listed in Table 3. If any of these are present, the patient should be referred for fetal echocardiography at 18 to 24 weeks of gestation.
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Absence or hypoplasia of umbilical artery
ICD 10 Indications
Q27.0
Advanced maternal age
ICD 10 Indications
O09.519 - O09.523 Maternal age of 35 years or older for a screening ultrasound from 12 through 27 weeks of gestation.
Amniotic fluid volume abnormalities
ICD 10 Indications
Oligohydramnios
O41.**Decreased amniotic fluid volume relative to gestational age, characterized by an amniotic fluid index (AFI) less than 5 cm or single deepest pocket less than 2 cm.
Polyhydramnios
O40 – O40.9 Increased amniotic fluid volume relative to gestational age characterized by an AFI greater than or equal to 24 cm.
Antiphospholipid Syndrome
ICD 10 Indications
Antiphospholipid syndrome (APS) or other maternal autoimmune disease
D68.51 - D68.62, M32.10 (Systemic Lupus Erythematosus), L93.0 (Discoid Lupus Erythematosus), L93.2 (Other Local Eupus Erythematosus)
Documented previous diagnosis of antiphospholipid syndrome (APS), or other maternal autoimmune disease, such as Systemic Lupus Erythematosis (SLE).
Autoimmune antibodies, anti-Ro (SSA)/anti-La (SSB)
D89.89 Documented previous diagnosis of autoimmune antibodies – anti-Ro (SSA)/anti-La (SSB)
Table 3: Diagnostic Codes related to Maternal/Fetal Conditions (not all-inclusive)
** Indicates multiple code variations for the diagnosis
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Asthma
ICD 10 Indications
J45.** Severe, documented asthma requiring daily medication such as long-acting beta-agonist and/or inhaled or oral steroids.
Blood Incompatibility
ICD 10 Indications
Rhesus isoimmunization affecting management of mother, antepartum condition or complication
O36.01**, O36.09**
Isoimmunization from other and unspecified blood-group incompatibility affecting management of mother, antepartum condition or complication
O36.11**, O36.19**
Cardiac
ICD 10 Indications
Cardiac Disease, Maternal
I51.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
Mitral valve disorder, aortic valve disorders, tricuspid valve disorders, specified as nonrheumatic, and pulmonary valve disorders
I05.9, I36.9, I37.0 Documented diagnosis affecting maternal-fetal condition during pregnancy
Endomyocardial fibrosis
I42.3 Documented diagnosis affecting maternal-fetal condition during pregnancy
Endocardial fibroelastosis
I42.4 Documented diagnosis affecting maternal-fetal condition during pregnancy
Alcoholic cardiomyopathy
I42.6 Documented diagnosis affecting maternal-fetal condition during pregnancy
Cardiomegaly
I51.7 Documented diagnosis affecting maternal-fetal condition during pregnancy
Congenital cardiovascular disorders
Q24.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
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Cardiac (continued)
ICD 10 Indications
Other cardiovascular diseases
I51.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
Personal history of surgery to heart and great vessels
Z98.89 Personal history of surgery to heart and great vessels
Abnormality in fetal heart rate or rhythm, antepartum condition or complication [suspected or documented fetal arrhythmia]
O76 Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm before the onset of labor, affecting fetus or newborn
P03.810 Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm, unspecified as to time of onset, affecting fetus or newborn
P03.819 Documented fetal arrhythmia during current pregnancy
Abnormal finding on antenatal screening
28.9 Abnormal finding on antenatal screening
Family history of other cardiovascular diseases
Z82.49 First degree relative with history of congenital heart disease
Bulbus cordis anomalies and anomalies of cardiac septal closure, other congenital anomalies of heart, other congenital anomalies of circulatory system, and anomalies of great veins
Q20.8, Q21.8 Documented diagnosis affecting maternal-fetal condition during pregnancy
Nonspecific abnormal findings on radiological and other exam of other intrathoracic organs [abnormal or incomplete cardiac evaluation on an anatomic scan, four-chamber study]
R93.1, R93.8 Documented diagnosis affecting maternal-fetal condition during pregnancy
Extracardiac anomaly
Q89.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
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Cardiac (continued)
ICD 10 Indications
Other cardiovascular diseases
I51.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
Personal history of surgery to heart and great vessels
Z98.89 Personal history of surgery to heart and great vessels
Abnormality in fetal heart rate or rhythm, antepartum condition or complication [suspected or documented fetal arrhythmia]
O76 Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm before the onset of labor, affecting fetus or newborn
P03.810 Documented fetal arrhythmia during current pregnancy
Abnormality in fetal heart rate or rhythm, unspecified as to time of onset, affecting fetus or newborn
P03.819 Documented fetal arrhythmia during current pregnancy
Abnormal finding on antenatal screening
28.9 Abnormal finding on antenatal screening
Family history of other cardiovascular diseases
Z82.49 First degree relative with history of congenital heart disease
Bulbus cordis anomalies and anomalies of cardiac septal closure, other congenital anomalies of heart, other congenital anomalies of circulatory system, and anomalies of great veins
Q20.8, Q21.8 Documented diagnosis affecting maternal-fetal condition during pregnancy
Nonspecific abnormal findings on radiological and other exam of other intrathoracic organs [abnormal or incomplete cardiac evaluation on an anatomic scan, four-chamber study]
R93.1, R93.8 Documented diagnosis affecting maternal-fetal condition during pregnancy
Extracardiac anomaly
Q89.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
Cervical Length Screening
ICD 10 Indications
O26.879 Documented physician concern about risk of premature delivery in support of a screen for cervical length shortening in low-risk, asymptomatic patient.
Cholestasis of pregnancy
ICD 10 Indications
O26.619 Documented elevated serum bile acid (upper limit of normal is between 10 and 14 μmol/L). or physician diagnosis based on patient symptoms.
Chromosomal Abnormalities and CHD
ICD 10 Indications
Down’s syndrome
Q90
Ehlers-Danlos syndrome
Q79.6
Edward’s syndrome
Q91.2
Trisomy 13
Q91.7
Trisomy 18
Q91.3
Turner’s syndrome
Q96.*
Cri du chat syndrome
Q93.4
Wolf-Hirshhorn syndrome
Q93.3
DiGeorge syndrome (deletion 22q11)
D82.1
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Decreased Fetal Movement
ICD 10 Indications
O36.81** Documented maternal perception of decreased fetal activity.
Diabetes Mellitus
ICD 10 Indications
Diabetes Mellitus - Gestational
O24.** Controlled by diet, without requiring medications.
Diabetes mellitus-Type I or Type II, pre-gestational
E08-E13.** Controlled by diet, without requiring medications.
Diabetes mellitus complicating pregnancy
O24.91* Controlled by diet, without requiring medications.
Syndrome of “infant of a diabetic mother”, fetus or newborn
P70.* Controlled by diet, without requiring medications.
Long-term (current) use of insulin
Z79.4 Diabetes diagnosed prior to pregnancy requiring medication (e.g. insulin, glyburide) to control.
Drug/ETOH abuse, or methadone use/abuse
ICD 10 Indications
F10-F16.**, F18-F19.** Active, documented in chart.
Epilepsy
ICD 10 Indications
Epilepsy and recurrent seizures
G40.** Documented diagnosis affecting maternal-fetal condition during pregnancy
Epilepsy complicating pregnancy
G40.909 Documented diagnosis affecting maternal-fetal condition during pregnancy
Convulsions
R.56.9 Documented diagnosis affecting maternal-fetal condition during pregnancy
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Epilepsy (continued)
ICD 10 Indications
Post traumatic seizures
R56.1 Documented diagnosis affecting maternal-fetal condition during pregnancy
Adverse effects of other and unspecified anticonvulsants
T42.**** Documented diagnosis affecting maternal-fetal condition during pregnancy
Fetal Abnormality
ICD 10 Indications
Fetal anomaly, major
F10-F16.**, F18-F19.** Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Multiple congenital anomalies
Q89.7 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Family history of congenital anomalies
Z82.79 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Central nervous system malformation in fetus affecting management of mother, antepartum condition or complication
O35.0XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Known or suspected chromosomal abnormality in fetus affecting management of mother, antepartum condition or complication
O35.1XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Hereditary disease in family possibly affecting fetus affecting management of mother, antepartum condition or complication
O35.2XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Suspected damage to fetus from viral disease in mother, antepartum condition or complication
O35.3XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
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Fetal Abnormality (continued)
ICD 10 Indications
Suspected damage to fetus from other disease affecting management of mother, antepartum condition or complication
O35.4XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Suspected damage to fetus from drugs affecting management of mother, antepartum condition or complication
O35.5XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Other known or suspected fetal abnormality, not elsewhere classified, antepartum condition or complication
O35.8XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Unspecified known or suspected fetal abnormality, not elsewhere classified, affecting management of mother, antepartum condition or complication
O35.9XX0 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Other nonspecific abnormal findings on radiological and other examination of body structure
R93.8 Suspected or known major structural anomaly, including documented history of previous congenital anomaly.
Poor fetal growth affecting management of mother
O36.5***Estimated fetal weight less than the 10th percentile for gestational age Scifres or an estimated fetal weight between the 10th and 15th percentile for gestational age.
Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication
ICD 10 Indications
O43.011 Fetal-maternal hemorrhage affecting management of mother, antepartum condition or complication (ex. vasa previa)
Fetal size/due date discrepancy
ICD 10 Indications
O26.84 A significant discrepancy of 3 or more between fundal height (centimeters) to gestational age (weeks).
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Fetus or newborn affected by placental transfusion syndromes
ICD 10 Indications
P02.3, O43.0, P50.3 Fetus or newborn affected by placental transfusion syndromes
Hereditary hemorrhagic telangiectasia
ICD 10 Indications
I78.0 Hereditary hemorrhagic telangiectasia
Hydrocephalic fetus causing disproportion, antepartum condition or complication
ICD 10 Indications
O33.6XX0 Hydrocephalis
Hydrops fetalis not due to isoimmunization, fetus or newborn
ICD 10 Indications
P83.2 Hydrops fetalis not due to isoimmunization, fetus or newborn
Hypertension, chronic
ICD 10 Indications
O10.**, I11.** Blood pressure ≥ 140 mm Hg systolic and/or 90 mm Hg diastolic, diagnosed before conception or before twenty (20) weeks gestation.
Hyperthyroid disease, maternal
ICD 10 Indications
O99.28* Uncontrolled, defined by suppressed TSH level with related maternal symptoms.
Hypothyroid disease, maternal
ICD 10 Indications
O99.28* Uncontrolled, defined by elevated thyroid stimulating hormone (TSH) and related maternal symptoms.
Human Immunodeficiency Virus (HIV) infection, maternal
ICD 10 Indications
098.7* Confirmed HIV, documented in chart.
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Incompetent cervix and no cerclage
ICD 10 Indications
034.**, N88.3 Premature opening of the cervix.
Increased nuchal translucency
ICD 10 Indications
Z36 Increased nuchal translucency
Infection
ICD 10 Indications
Other specified infectious and parasitic diseases of mother, antepartum condition or complication
O98.61*, O98.81* Other specified infectious and parasitic diseases of mother, antepartum condition or complication
Unspecified infection or infestation of mother, antepartum condition or complication
O98.91* Unspecified infection or infestation of mother, antepartum condition or complication
Unspecified viral infection
B97.89 Unspecified viral infection
Suspected damage to fetus from viral disease in the mother, affecting management of mother, antepartum condition or complication
O35.3XX0 Suspected damage to fetus from viral disease in the mother, affecting management of mother, antepartum condition or complication
Intrauterine Fetal Death (IUFD), history
ICD 10 Indications
O09.211 Documented history of IUFD.
Intrauterine Growth Restriction (IUGR)
ICD 10 Indications
P05.9Estimated fetal weight less than the 10th percentile for gestational age Scifres or an estimated fetal weight between the 10th and 15th percentile for gestational age.
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Malpresentation
ICD 10 Indications
032.*** Presentation other than vertex after 36 weeks.
Mental disorders complicating pregnancy, antepartum condition or complication
ICD 10 Indications
O99.34* Mental disorders complicating pregnancy, antepartum condition or complication
MSAFP (Maternal serum alpha-fetoprotein) level, elevated
ICD 10 Indications
Z36 Unexplained, elevated MSAFP, > 2.5 MoMs (quantitative unit of measure for MSAFP reported as multiples of the median).
Multiple gestations
ICD 10 Indications
O30-O31.** Two or more fetuses.
Monochorionic twins
O30.1 Twins that share a placenta and an outer membrane.
Twin gestation, monochorionic/diamnionic
O30.039 Twins that share a placenta and outer membrane
Noxious Influences
ICD 10 Indications
Noxious influences affecting fetus or newborn via placenta or breast milk, alcohol
P04.3, Q86.0 Active, documented in chart.
Noxious influences affecting fetus or newborn via placenta or breast milk, anticonvulsants
P04.1 Documented medication use, affecting maternal-fetal condition during pregnancy
Antimetabolic agents affecting fetus or newborn via placenta or breast milk
P04.1 Documented medication use, affecting maternal-fetal condition during pregnancy
Noxious influences affecting fetus via placenta or breast milk, other
P04.8 Noxious influences affecting fetus via placenta or breast milk, other
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Obesity in pregnancy
ICD 10 Indications
O99.21* Maternal body mass index (BMI) > 30 kg/m2 conception (usually determined during first obstetrical exam).
Other specified antenatal screening [when reported alone - indicates routine screen without signs or symptom
ICD 10 Indications
Z36 Other specified antenatal screening
Other specified complications of pregnancy, antepartum condition or complication
ICD 10 Indications
O26.1**, O26.4**, O26.8** Other specified complications of pregnancy, antepartum condition or complication
PAPP-A (Pregnancy-associated plasma protein A), abnormal value
ICD 10 Indications
O35.** Unexplained, <0.3 MoMs (multiples of the median).
Phenylketonuria
ICD 10 Indications
E70.1 Phenylketonuria
Placenta previa
ICD 10 Indications
O44.** Asymptomatic (without bleeding) with documented prior ultrasound report of placenta located near or over the internal cervical orifice.
Placental abruption
ICD 10 Indications
O45.** Vaginal bleeding with suspected placental abruption.
Post term pregnancy
ICD 10 Indications
O48.** Pregnancy that is at or beyond forty (40) weeks of gestation
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Pre-eclampsia
ICD 10 Indications
O10.*** and additional codes
New onset of blood pressure elevation exceeding 140/90 mm Hg after twenty (20) weeks gestation.
Pregnancy resulting from assisted reproductive technology
ICD 10 Indications
O09.819 Pregnancy resulting from assisted reproductive technology
Premature rupture of membranes
ICD 10 Indications
O42.0** Confirmed and documented in chart.
Pre-term delivery history
ICD 10 Indications
Z87.51 Patient has had a previous pregnancy that delivered between 20 and 37 weeks of gestation.
Pre-term delivery risk screening of low-risk patient (cervical shortening)
ICD 10 Indications
N88.3 Documented concern that supports need for transvaginal ultrasound to screen for cervical length shortening.
Pre-term labor
ICD 10 Indications
O60.1*** Active labor defined as regular painful contractions (≥4 in 20 minutes or ≥8 in one hour) and documented cervical change.
Rare Genetic Diseases
ICD 10 Indications
Situs inversus
Q89.3 Situs inversus
Marfan syndrome
Q87.40 Marfan syndrome
Smith-Lemli-Opitz syndrome
E78.72 Smith-Lemli-Opitz syndrome
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Rare Genetic Diseases (continued)
ICD 10 Indications
Ellis-van Creveld
Q77.6 Ellis-van Creveld
Holt-Oram syndrome
Q23.8, Q24.8 Holt-Oram syndrome
Noonan syndrome
Q87.1 Noonan syndrome
Mucopolysaccharidoses
E76.** Mucopolysaccharidoses
Goldenhar syndrome (hemifacial microsomia)
Q75.9 Goldenhar syndrome (hemifacial microsomia)
Other Congenital Anomalies (VACTERL association [tracheal and esophageal malformations associated with vertebral, anorectal, cardiac, renal, radial, and limb abnormalities], William’s syndrome)
E78.71, Q87.**, Q89.8
Other Congenital Anomalies (VACTERL association [tracheal and esophageal malformations associated with vertebral, anorectal, cardiac, renal, radial, and limb abnormalities], William’s syndrome)
Renal disease, maternal
ICD 10 Indications
O26.839 Documented history of parenchymal renal disease prior to pregnancy.
Rheumatoid arthritis
ICD 10 Indications
M06.9 Rheumatoid arthritis
Rubella exposure
ICD 10 Indications
B06.9 Rubella exposure
Screening for malformation using ultrasonics [when reported alone - indicates routine screen without signs or symptoms]
ICD 10 Indications
Z36 Screening for malformation using ultrasonics [when reported alone - indicates routine screen without signs or symptoms]
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Sicca syndrome (Sjörgen’s syndrome)
ICD 10 Indications
M35 Sicca syndrome
Sickle cell disease, maternal
ICD 10 Indications
D57.1 Documented maternal sickle cell disease (not just trait)
Systemic sclerosis
ICD 10 Indications
M34 Systemic sclerosis
Teratogen (eg. Retinoid) exposure
ICD 10 Indications
Z20 Teratogen (eg. Retinoid) exposure
Unspecified diffuse connective tissue disease
ICD 10 Indications
L94.9 Unspecified diffuse connective tissue disease
Vaginal bleeding
ICD 10 Indications
N93.9, O20.0 Suspected placental abruption, suspected placenta previa, suspected spontaneous abortion, etc.
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Situations beyond the medical conditions above:
Please note that indications adjunct to procedures (an ultrasound may be indicated for amniocentesis, amnioinfusion, cervical cerclage, fetoscopy, shunt placement, etc) and other high-risk medical conditions not listed above will be allowed antenatal testing upon request.
Three-dimensional (3D) and four-dimensional (4D) Ultrasounds are considered experimental and investigational as there is no evidence that they alter management over a two-dimensional (2D) ultrasound in a way that improves outcomes.
Common codes not covered for Fetal Echo (not all-inclusive).
ICD 10 Description
099.810 - 099.815 Abnormal glucose tolerance complicating pregnancy
009.511 - 009.519 Elderly primigravida [screening]
009.521 - 009.529 Elderly multigravida [screening]
Z13.228 Special screening for endocrine, nutritional, metabolic and immunity disorders [screening for cystic fibrosis]
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ReferencesAmerican College of Radiology. (2014). ACR Appropriateness Criteria® Retrieved from https://acsearch.acr.org/list
American Institute of Ultrasound in Medicine. (2010). AIUM practice guideline for the performance of obstetric ultrasound examinations. J Ultrasound Med, 9(1), 157-166. Retrieved from http://www.jultrasoundmed.org/content/29/1/157.full.pdf+html
American Institute for Ultrasound in Medicine (AIUM). AIUM practice guideline for the performance of fetal echocardiography. Laurel, MD: AIUM; 2010. Available at: https://www.smfm.org/attachedfiles/fetalEchoaiumsmfm.pdf Accessed July 29, 2015
Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA Guidelines for the clinical application of echocardiography: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Clinical Application of Echocardiography). Developed in collaboration with the American Society of Echocardiography. J Am Coll Cardiol. 1997;29(4):862-879.
Davies, G.A.L., Maxwell, C., McLeod, L., Gagnon, R., Basso, M., Bos, H., … Society of Obstetricians and Gynaecologists of Canada. (2010). SOGC clinical practice guideline: Obesity in pregnancy. J Obstet Gynaecol Can, 32, 165. Retrieved from http://www.ncbi.nlm.nih.gov
Desilets V, Audibert F; Society of Obstetrician and Gynaecologists of Canada. Investigation and management of non-immune fetal hydrops. J Obstet Gynaecol Can. 2013; 35(10):923-938.
Freeman, R.K. (2008). Antepartum testing in patients with hypertensive disorders in pregnancy. Semin Perinatol, 32(4), 271-273. doi: 10.1053/j.semperi.2008.04.009.
Wilson KL, Czerwinski JL, Hoskovec JM, et al. NSGC practice guideline: Prenatal screening and diagnostic testing options for chromosome aneuploidy. J Genet Couns. 2013; 22(1):4-15.
Source: CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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