Coding Guideline For Maternal-Fetal Medicine

Determining when to refer a patient to MFM can be complex. MFM services don't align neatly with standard obstetric billing blocks. They're not part of the 90-day global, nor do they fall under a zero global. Unlike chronic conditions, pregnancy is temporary, and managing both maternal and fetal considerations adds further complexity.

In such cases, the following coding guidelines can help clarify when and how to involve MFM services appropriately.

What Is Maternal-Fetal Medicine?

Maternal-Fetal Medicine (MFM) is a recognized subspecialty of obstetrics and gynecology that focuses on the care of patients experiencing complications during pregnancy and childbirth. The care may involve the mother, the fetus, or both, depending on the clinical situation. MFM specialists typically provide consultative services and may not be the ones performing deliveries; however, they often play a key role in determining when delivery should occur.

This subspecialty has its taxonomy code 207VM0101X, which is essential to consider during credentialing. Accurate classification under this code can significantly impact reimbursement outcomes, making it a critical detail for both administrative and billing purposes.

Understanding Global Obstetric Care vs. MFM Consultative Services

The global obstetric care package covers routine prenatal visits, delivery, and postpartum care. According to CPT guidelines, the following codes apply based on the delivery method:

• 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care
• 59510 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care
• 59610 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy and/or forceps), and postpartum care, after a previous cesarean delivery

These codes generally encompass 13–15 prenatal visits, although the exact number may vary based on when the patient initiates care, the timing of delivery, and maternal-fetal health factors. Postpartum care typically spans six weeks, though some payers may extend this to eight weeks.

Services Not Included in the Global OB Package

CPT guidelines specifically exclude the following from the global obstetric package:

• Ultrasound
• Amniocentesis
• Biophysical profile (BPP)
• Fetal non-stress test (NST)
• Consultations
• Hospital admissions

Important Note: Some payers may choose to bundle ultrasounds into the global package if they become part of a provider’s standard of care. For example, if a provider consistently performs a 16-week ultrasound, payers may interpret this as routine and include it in the bundled reimbursement.

 

First Trimester Obstetric Ultrasound Coding and Documentation

When coding for obstetric ultrasounds, it's essential to consider the gestational age, number of fetuses, and the medical necessity for the scan. In the first trimester (before 14 weeks, 0 days), providers may perform ultrasounds to assess fetal structures, count gestational sacs, evaluate amniotic fluid, and examine maternal anatomy.

The appropriate CPT codes for this service are:

• 76801 – Ultrasound, pregnant uterus, real-time with image documentation; fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation
• +76802 – Each additional gestation (add-on code, reported in addition to 76801)

Key Documentation Requirements

Payers require documentation that includes a precise evaluation of maternal structures. This component is often missed in clinical records. If visualization of maternal anatomy isn't possible, the reason must be explicitly stated in the documentation.

Important:

• Fetal gender determination does not support medical necessity.
• "Size/dates" alone is not sufficient to justify an ultrasound.

Ensuring thorough and compliant documentation helps avoid denials and supports appropriate reimbursement.

Obstetric Ultrasound Coding by Trimester, Indication, and CPT Code

Proper ultrasound coding in obstetric care depends on several key factors, including gestational age, clinical purpose, number of fetuses, and medical necessity. Below is a comprehensive breakdown of ultrasound services by category, including all relevant CPT codes.

First Trimester Screening (Fetal Nuchal Translucency)

First-trimester screening evaluates the risk of chromosomal abnormalities and involves both ultrasound and maternal blood testing. The ultrasound focuses on the fetal neck, nuchal translucency, and general fetal measurements.

• 76813 – Ultrasound, first trimester fetal nuchal translucency measurement; single or first gestation
• +76814 – Each additional gestation (List separately in addition to code for primary procedure)

First Trimester Diagnostic Ultrasound (<14 Weeks 0 Days)

This ultrasound may be performed to confirm gestational age, count the number of sacs, and assess fetal and maternal anatomy.

• 76801 – Ultrasound, first trimester, transabdominal approach; single or first gestation
• +76802 – Each additional gestation (Add-on code)

Documentation must include an assessment of both fetal and maternal structures, along with a rationale if maternal anatomy is not visualized. Fetal gender or "size/dates" alone does not justify medical necessity.

Second and Third Trimester Ultrasound (≥14 Weeks 0 Days)

Used for evaluation of fetal growth, organ systems, amniotic fluid, placental location, and maternal adnexa.

• 76805 – Ultrasound, after first trimester, transabdominal approach; single or first gestation
• +76810 – Each additional gestation (Add-on code)

Documentation should include:

• Number of fetuses
• Number of amniotic/chorionic sacs
• Intracranial/spinal and abdominal anatomy
• Four-chamber heart
• Umbilical cord insertion
• Placental location
• Amniotic fluid volume
• Maternal adnexa (if visible)

If maternal structures are not visualized, the reason (e.g., fetal positioning) must be documented.

Detailed Fetal Anatomical Ultrasound

This code is reserved for expanded anatomical surveys when additional evaluation is required beyond a standard 76805 exam.

• 76811 – Detailed fetal anatomical ultrasound, transabdominal approach; single or first gestation
• +76812 – Each additional gestation (Add-on code)

76811 includes all components of 76805, plus a detailed assessment of brain, ventricles, face, heart outflow tracts, chest, abdominal organs, limbs, placenta, umbilical cord, and other indicated anatomy.

Medical necessity must be documented — i.e., what was found during 76805 that led to 76811. You cannot bill 76811 alone without supporting findings.

Transvaginal Ultrasound

Performed to assess the cervix or lower uterine structures (e.g., funneling or membrane issues).

• 76817 – Ultrasound, transvaginal approach; real-time with image documentation

Can be billed alongside 76801 or 76805 if clinically appropriate, as different approaches are used.

Follow-Up and Limited Obstetric Ultrasound

Used for re-evaluation or targeted assessments (e.g., fetal heartbeat, position, or fluid).

• 76815 – Limited obstetric ultrasound, 1 or more fetuses (bill only once per session)
• 76816 – Follow-up ultrasound, per fetus (billable per fetus)

Modifier 51 is not required for separately billable ultrasounds. These codes do not include time spent on result discussions; such services are billed separately.

Biophysical Profile (BPP) Coding

A Biophysical Profile (BPP) is a physiological assessment, not an anatomic ultrasound. It evaluates fetal well-being by assessing fetal heart rate, breathing movements, and amniotic fluid volume. Depending on the clinical scenario, a Non-Stress Test (NST) may or may not be performed in conjunction with the ultrasound.

CPT Codes for BPP:

• 76818 – Fetal biophysical profile; with non-stress testing
• 76819 – Fetal biophysical profile; without non-stress testing

These codes are commonly used when managing pregnancies complicated by conditions such as hypertension, gestational or pregestational diabetes, coagulation disorders, or multiple gestations, among others.

Codes for Amniocentesis and Invasive Fetal Procedures

Amniocentesis may be performed for either diagnostic or therapeutic purposes. In diagnostic cases, the collected amniotic fluid is typically sent to the laboratory for genetic analysis or testing for infections.

CPT Codes for Diagnostic Amniocentesis

• 59000 – Amniocentesis; diagnostic
• 76946 – Ultrasonic guidance for amniocentesis, imaging supervision, and interpretation

Note: While 59000 often does not require prior authorization, the genetic testing performed on the sample usually does, and should be confirmed with the payer in advance.

For patients at high risk, therapeutic amniocentesis procedures may be necessary. These are less common and typically address conditions involving fluid imbalance or fetal complications.

CPT Codes for Therapeutic Procedures (Includes Ultrasound Guidance)

• 59001 – Amniocentesis; therapeutic amniotic fluid reduction
• 59070 – Transabdominal amnioinfusion
• 59074 – Fetal fluid drainage (e.g., vesicocentesis, thoracocentesis, paracentesis)
• 59076 – Fetal shunt placement

In certain high-risk pregnancies, your MFM specialist may also perform invasive fetal procedures such as cordocentesis or intrauterine transfusion.

Additional Invasive Procedure Codes

• 59012 – Cordocentesis (intrauterine), any method
• 36460 – Transfusion, intrauterine, fetal
• 76941 – Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, including imaging supervision and interpretation

Clinical Notes

• Cordocentesis involves sampling blood from the umbilical cord and is typically performed after 18 weeks’ gestation to assess for fetal infections, anemia, or chromosomal abnormalities.
• Intrauterine transfusion (36460) is generally used to treat Rh incompatibility by delivering blood directly to the fetus.

ICD-10-CM Considerations for MFM and High-Risk Obstetrics

One of the foundational rules in ICD-10-CM is that Chapter 15 codes (Pregnancy, Childbirth, and the Puerperium) must be sequenced first when applicable, regardless of the setting or specialty involved in the patient’s care.

Important Reminder

Specialists, such as nephrologists, cardiologists, or ophthalmologists, may default to using diagnosis codes from their respective specialty chapters. However, if the patient is pregnant, Chapter 15 codes must take priority, even when care is provided outside of the obstetrics setting.

According to coding guidance, nearly every obstetric condition has an appropriate code within Chapter 15. The provider must clearly state if a presenting condition is complicating the pregnancy, as this impacts both coding and reimbursement. Hospital length-of-stay approvals, for instance, may be limited based on pregnancy-related criteria rather than the complicating condition alone.

Common Chapter 15 ICD-10 Codes

Maternal Conditions:

• O24 – Diabetes mellitus in pregnancy
• O10–O15 – Hypertensive disorders
• O99.1 – Coagulation defects
• O99.35 – Epilepsy complicating pregnancy

Fetal Conditions:

• O30 – Multiple gestation
• O36.5x–O36.6x – Fetal size discrepancies
• O36.0 – Maternal isoimmunization
• O36.82 – Fetal anemia
• O36.83 – Abnormal fetal heart rate or rhythm
• O36 – Malposition or malpresentation

Additional Notes:

• Always include an outcome code (Z37.-) when appropriate.
• When the complexity of a case warrants additional work (e.g., due to a high-risk status), a Modifier 22 (Increased Procedural Services) may be appended, provided that clear documentation supports this.

Understanding Multiple Gestation Anatomy

Ultrasound reports often use terms like Di/Di (dichorionic/diamniotic), Mono/Di, or Mono/Mono, referring to chorionicity and amnionicity. Understanding these terms helps in selecting the correct diagnosis codes for multiple gestations. This is especially relevant when confirming fetal anatomy via ultrasound.

Tip: Collaborate with providers to define what constitutes a high-risk pregnancy (O09 category) in your practice. This can vary and is primarily based on the physician’s clinical judgment.

Coding Tips for Maternal-Fetal Medicine

Keep the following points in mind when coding for maternal-fetal medicine (MFM) services:

• Dual Ultrasound Billing: When both transabdominal and transvaginal ultrasounds are medically necessary and performed, you may report both, assuming documentation supports it.
   
• Modifier 26 Usage: For procedures performed in a hospital or facility setting, append modifier 26 to indicate the professional component only.
   
• Biophysical Profile (BPP) for Multiples: Always verify payer-specific rules for reporting BPP in multiple gestations. Some payers accept billing as 76818 x 3, while others require sequencing with modifier 59 (e.g., 76818, 76818-59, 76818-59).
   
• Ultrasound Add-On Codes: Add-on ultrasound codes (e.g., +76802, +76810) do not require modifiers 51 or 59.
   
• Non-Stress Tests (NSTs): For multiple gestations or when billing multiple NSTs, use modifier 59 to indicate separate and distinct procedures when appropriate.
   

BillingFreedom: Your Trusted Partner in Maternal-Fetal Medicine Coding and Billing

BillingFreedom specializes in the complexities of OB and Maternal-Fetal Medicine (MFM) billing, offering expert solutions that align with CPT and ICD-10-CM guidelines. From high-risk pregnancy diagnosis coding to procedure-specific claims for ultrasounds, BPPs, NSTs, and invasive fetal procedures, our team ensures accurate documentation, proper modifier use, and payer-specific compliance, maximizing reimbursements while minimizing denials.

Our certified coders understand that MFM services fall outside typical global OB packages and require tailored, consultative billing strategies. Whether it’s applying modifiers like 26 and 59 correctly, navigating Chapter 15 sequencing rules, or managing detailed claims for procedures like amniocentesis and cordocentesis, BillingFreedom delivers precision and efficiency. Partner with us to ensure your maternal-fetal care services are coded and billed with confidence and compliance.

For more details about our exceptional Maternal-Fetal Medicine medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472. 

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