Ultrasound Billing Guidelines During Pregnancy (CPT Codes, Diagnosis & Frequency)

Pregnancy-related ultrasounds are a critical component of prenatal care, but their billing and reimbursement are governed by specific guidelines to ensure medical necessity and compliance. Routine screening ultrasounds are included in the global obstetrical fee, while additional ultrasounds are reimbursable only when linked to approved diagnoses, frequency limits, and proper documentation. Understanding CPT codes, diagnosis restrictions, and frequency requirements is essential for accurate claim submission, avoiding denials, and ensuring that both providers and patients benefit from appropriate, medically justified ultrasound services.

Ultrasound During Pregnancy – Policy

An ultrasound performed for routine screening during pregnancy is considered an integral part of the patient’s prenatal care, and reimbursement is included in the obstetrical fee. Ultrasound during pregnancy is separately reimbursable only when it is performed for the diagnosis or treatment of specific medical conditions.

Diagnosis, Frequency, and Documentation Guidelines of Ultrasound Billing Guidelines During Pregnancy

Ultrasound services are reimbursable as defined below:

• The diagnosis on the claim must correspond appropriately with the CPT code being billed.
• Frequency of services must comply with the restrictions outlined.
• Certain claims require documentation in the Remarks field (Box 80) or the Additional Claim Information field (Box 19) to support medical necessity.

Note: For the most current list of codes, frequency limits, and documentation requirements, refer to the Pregnancy: Early Care and Diagnostic Services (preg early) section of the Part 2 provider manual.

Reimbursable Ultrasound Codes

The following ultrasound procedures are eligible for separate reimbursement when linked to specific diagnoses and billed within the defined frequency and documentation limits.

CPT Codes: 76801, 76805, 76811

Diagnosis Restrictions
These codes are payable only for the following conditions:

• 000.0 – 002.9: Ectopic, hydatidiform mole, and other abnormal products of conception
• 003.0 – 003.9: Spontaneous abortion
• 009.511 – 009.513: Elderly primigravida
• 009.521 – 009.523: Elderly multigravida
• 010.011 – 016.9: Edema, proteinuria, and hypertensive disorders
• 020.0 – 021.9, 023.00 – 029.93: Other maternal disorders
• 030.001 – 048.1: Maternal care related to fetus and amniotic cavity
• 060.00 – 060.03: Preterm labor without delivery
• 098.011 – 098.919: Maternal infectious and parasitic diseases
• 099.011 – 099.419, 099.511 – 099.89: Other maternal diseases classifiable elsewhere
• 09A.111 – 09A.519: Maternal malignant neoplasms, traumatic injuries, and abuse
• Z33.2: Encounter for elective termination of pregnancy
• Z36.0 – Z36.9: Encounter for antenatal screening of mother

Frequency and Documentation Requirements

• Limited to once in 180 days for the same provider.
• Additional claims within this period are reduced to the 76816 rate, even when documentation is provided to justify medical necessity.
• Exceptions apply only if documentation confirms that a new pregnancy has occurred.

CPT Codes: 76802, 76810, 76812

Diagnosis Restrictions
These codes are reimbursable only for the following conditions:

• 000.0 – 002.9: Ectopic, hydatidiform mole, and other abnormal products of conception
• 003.0 – 003.9: Spontaneous abortion
• 004.5 – 004.89: Complications following (induced) termination of pregnancy
• 009.511 – 009.513: Elderly primigravida
• 030.001 – 048.1: Maternal care related to fetus and amniotic cavity
• 060.00 – 060.03: Preterm labor without delivery
• 098.011 – 098.919: Maternal infectious and parasitic diseases
• 099.011 – 099.419, 099.511 – 099.89: Other maternal diseases classifiable elsewhere
• 09A.111 – 09A.519: Maternal malignant neoplasms, traumatic injuries, and abuse
• Z33.2: Encounter for elective termination of pregnancy
• Z36.0 – Z36.9: Encounter for antenatal screening of mother

Frequency and Documentation Requirements

• Limited to four in 180 days for the same provider.
• Additional claims within this period are reduced to the 76816 rate, even if billed with documentation, unless records confirm that a new pregnancy has occurred.
• When billing for a pregnancy with multiple gestations, a maximum of four per day is allowed.
• In such cases, the provider must clearly document the number of fetuses in the Remarks field (Box 80) or Additional Claim Information field (Box 19) of the claim.

CPT Code: 76813 (for nuchal translucency)

Diagnosis Restriction

• Z36.82: Encounter for antenatal screening

Frequency and Documentation Requirements

• Limited to one per day.
• The claim must include documentation confirming that the physician performing or supervising the ultrasound is credentialed by either the Nuchal Translucency Quality Review Program or the Fetal Medicine Foundation.

CPT Code: 76814 (for nuchal translucency, multiple gestations)

Diagnosis Restriction

• Z36.82: Encounter for antenatal screening

Frequency and Documentation Requirements

• A maximum of four per day is allowed when billing for a pregnancy with multiple gestations.
• The provider must specify the number of fetuses in the Remarks field (Box 80) or Additional Claim Information field (Box 19).
• The claim must also confirm that the physician performing or supervising the ultrasound is credentialed by either the Nuchal Translucency Quality Review Program or the Fetal Medicine Foundation.

CPT Code: 76815

Diagnosis Restrictions
Reimbursement applies only when the claim reflects one of the following:

• 000.0 – 002.9: Ectopic, hydatidiform mole, and other abnormal products of conception
• 003.0 – 003.9: Spontaneous abortion
• 004.5 – 004.89: Complications following (induced) termination of pregnancy
• 009.511 – 009.513: Elderly primigravida
• 009.521 – 009.523: Elderly multigravida
• 010.011 – 016.9: Edema, proteinuria, and hypertensive disorders
• 020.0 – 021.9, 023.00 – 029.93: Other maternal disorders
• 030.001 – 048.1: Maternal care related to fetus and amniotic cavity
• 060.00 – 060.03: Preterm labor without delivery
• 098.011 – 098.919: Maternal infectious and parasitic diseases
• 099.011 – 099.419, 099.511 – 099.89: Other maternal diseases classifiable elsewhere
• 09A.111 – 09A.519: Maternal malignant neoplasms, traumatic injuries, and abuse
• Z33.2: Encounter for elective termination of pregnancy
• Z36.0 – Z36.9: Encounter for antenatal screening of mother

Frequency and Documentation Requirements

• Limited to once in 180 days for the same provider.
• Additional claims may be reimbursed only if documentation clearly supports medical necessity.

CPT Code: 76816

Diagnosis Restrictions
This code is reimbursable for the following conditions:

• 000.0 – 002.9: Ectopic, hydatidiform mole, and other abnormal products of conception
• 003.0 – 003.9: Spontaneous abortion
• 004.5 – 004.89: Complications following (induced) termination of pregnancy
• 009.511 – 009.513: Elderly primigravida
• 009.521 – 009.523: Elderly multigravida
• 010.011 – 016.9: Edema, proteinuria, and hypertensive disorders
• 020.0 – 021.9, 023.00 – 029.93: Other maternal disorders
• 030.001 – 048.1: Maternal care related to fetus and amniotic cavity
• 060.00 – 060.03: Preterm labor without delivery
• 098.011 – 098.919: Maternal infectious and parasitic diseases
• 099.011 – 099.419, O99.511 – 099.89: Other maternal diseases classifiable elsewhere
• 09A.111 – 09A.519: Maternal malignant neoplasms, traumatic injuries, and abuse
• Z33.2: Encounter for elective termination of pregnancy
• Z36.0 – Z36.9: Encounter for antenatal screening of mother

Frequency and Documentation Requirements

• Reimbursable once in 180 days when billed without modifier 59, by the same provider.
• Additional claims may be reimbursed if documentation justifies medical necessity.
• For multiple gestations, providers must bill 76816 with modifier 59 (in any modifier position 1–4).
• Code 76816 with modifier 59 is payable for multiple gestations, even when another claim for the same date of service has already been paid.
• A maximum of four per day is allowed when billing for multiple gestations.
• Providers must document the number of fetuses in the Remarks field (Box 80) or Additional Claim Information field (Box 19).

CPT Code: 76817

Diagnosis Restrictions
This code is payable only when associated with the following conditions:

• 000.0 – 002.9: Ectopic, hydatidiform mole, and other abnormal products of conception
• 003.0 – 003.9: Spontaneous abortion
• 004.5 – 004.89: Complications following (induced) termination of pregnancy
• 009.511 – 009.513: Elderly primigravida
• 009.521 – 009.523: Elderly multigravida
• 010.011 – 016.9: Edema, proteinuria, and hypertensive disorders
• 020.0 – 021.9, 023.00 – 029.93: Other maternal disorders
• 030.001 – 048.1: Maternal care related to fetus and amniotic cavity
• 060.00 – 060.03: Preterm labor without delivery
• 098.011 – 098.919: Maternal infectious and parasitic diseases
• 099.011 – 099.419, 099.511 – 099.89: Other maternal diseases classifiable elsewhere
• 09A.111 – 09A.519: Maternal malignant neoplasms, traumatic injuries, and abuse
• Z33.2: Encounter for elective termination of pregnancy
• Z36.0 – Z36.9: Encounter for antenatal screening of mother

Frequency and Documentation Requirements

• Limited to once in 180 days by the same provider.
• Additional claims within this period may be reimbursed if medical necessity is clearly documented.

CPT Code: 76820

Diagnosis Restrictions

• 036.5110 – 036.5999: Maternal care for known or suspected poor fetal growth
• 041.00X0 – 041.03X9: Oligohydramnios
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 036.0110 – 036.0999: Maternal care for rhesus isoimmunization
• 036.1110 – 036.1999: Care for other isoimmunization
• 036.20X0 – 036.23X9: Maternal care for hydrops fetalis
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 098.511 – 098.519: Other viral diseases complicating pregnancy
• 024.011 – 024.02, 024.111 – 024.12, 024.311 – 024.32, 024.410 – 024.429, 024.811 – 024.82, 024.911 – 024.919: Pre-existing diabetes mellitus and gestational diabetes
• 035.0XX0 – 035.9XX9: Maternal care for known or suspected fetal abnormality and damage
• 036.8310 – 036.8399: Maternal care for abnormalities of the fetal heart rate or rhythm

Frequency and Documentation Requirements

• Limited to once in 180 days, same provider.
• Additional claims reimbursable with documentation of medical necessity.
• For multiple gestations, up to five per day are allowed.
• The number of fetuses must be documented in the Remarks field (Box 80)/Additional Claim Information field (Box 19).

CPT Code: 76821

Diagnosis Restrictions

• 036.5110 – 036.5999: Maternal care for known or suspected poor fetal growth
• 041.00X0 – 041.03X9: Oligohydramnios
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 036.0110 – 036.0999: Maternal care for rhesus isoimmunization
• 036.1110 – 036.1999: Care for other isoimmunization
• 036.20X0 – 036.23X9: Maternal care for hydrops fetalis
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 098.511 – 098.519: Other viral diseases complicating pregnancy
• 024.011 – 024.02, 024.111 – 024.12, 024.311 – 024.32, 024.410 – 024.429, 024.811 – 024.82, 024.911 – 024.919: Pre-existing diabetes mellitus and gestational diabetes
• 035.0XX0 – 035.9XX9: Maternal care for known or suspected fetal abnormality and damage
• 036.8310 – 036.8399: Maternal care for abnormalities of the fetal heart rate or rhythm

Frequency and Documentation Requirements

• Limited to once in 180 days.
• Additional claims reimbursable with documentation of medical necessity.
• For multiple gestations, a maximum of five per day.
• Providers must document the number of fetuses in the Remarks field (Box 80)/Additional Claim Information field (Box 19).

CPT Code: 76825

Diagnosis Restrictions

• 036.5110 – 036.5999: Maternal care for known or suspected poor fetal growth
• 041.00X0 – 041.03X9: Oligohydramnios
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 036.0110 – 036.0999: Maternal care for rhesus isoimmunization
• 036.1110 – 036.1999: Care for other isoimmunization
• 036.20X0 – 036.23X9: Maternal care for hydrops fetalis
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 098.511 – 098.519: Other viral diseases complicating pregnancy
• 024.011 – 024.02, 024.111 – 024.12, 024.311 – 024.32, 024.410 – 024.429, 024.811 – 024.82, 024.911 – 024.919: Pre-existing diabetes mellitus and gestational diabetes
• 035.0XX0 – 035.9XX9: Maternal care for known or suspected fetal abnormality and damage
• 036.8310 – 036.8399: Maternal care for abnormalities of the fetal heart rate or rhythm

Frequency and Documentation Requirements

• Limited to once in 180 days, same provider.
• Maximum five per day for multiple gestations.
• The number of fetuses must be recorded in the Remarks field (Box 80)/Additional Claim Information field (Box 19).

CPT Code: 76827

Diagnosis Restrictions

• 036.5110 – 036.5999: Maternal care for known or suspected poor fetal growth
• 041.00X0 – 041.03X9: Oligohydramnios
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 036.0110 – 036.0999: Maternal care for rhesus isoimmunization
• 036.1110 – 036.1999: Care for other isoimmunization
• 036.20X0 – 036.23X9: Maternal care for hydrops fetalis
• 043.021 – 043.029: Fetus-to-fetus placental transfusion syndrome
• 098.511 – 098.519: Other viral diseases complicating pregnancy
• 024.011 – 024.02, 024.111 – 024.12, 024.311 – 024.32, 024.410 – 024.429, 024.811 – 024.82, 024.911 – 024.919: Pre-existing diabetes mellitus and gestational diabetes
• 035.0XX0 – 035.9XX9: Maternal care for known or suspected fetal abnormality and damage
• 036.8310 – 036.8399: Maternal care for abnormalities of the fetal heart rate or rhythm

Frequency and Documentation Requirements

• Allowed once in 180 days.
• Maximum five per day for multiple gestations.
• Must document the number of fetuses in the Remarks field (Box 80)/Additional Claim Information field (Box 19).

CPT Codes: 76826, 76828

Diagnosis Restrictions

• 024.011 – 024.02, 024.111 – 024.12, 024.311 – 024.32, 024.410 – 024.429, 024.811 – 024.82, 024.911 – 024.919: Pre-existing diabetes mellitus and gestational diabetes
• 035.0XX0 – 035.9XX9: Maternal care for known or suspected fetal abnormality and damage
• 036.8310 – 036.8399: Maternal care for abnormalities of the fetal heart rate or rhythm

Frequency and Documentation Requirements

• Limited to once in 180 days, same provider.
• Additional claims may be reimbursed if documentation proves medical necessity.
• For multiple gestations, five per day maximum.
• The number of fetuses must be documented in the Remarks field (Box 80)/Additional Claim Information field (Box 19).

Ultrasound Common Billing Denial

• Remittance Advice Details (RAD) code 9109: This service is not payable for the diagnosis billed.

Billing Tip: Always confirm that the diagnosis code matches the CPT procedure.

Note: Refer to Remittance Advice Details (RAD) and Medi-Cal Financial Summary (remit) section of the Part 1 provider manual for details. See Remittance Advice Details (RAD) Codes, Messages, and Electronic Correlations for further guidance.

BillingFreedom’s Expertise in OBGYN Ultrasound Billing Compliance

Managing ultrasound billing during pregnancy requires not only attention to CPT coding but also accuracy in diagnosis linkage, adherence to frequency restrictions, and adherence to documentation standards. In California, BillingFreedom has supported OB-GYN providers by streamlining claims in line with these complex requirements. Over recent years, practices working with our team have observed measurable improvements, including a 92% clean claim submission rate and a notable 35% reduction in denial trends within OBGYN medical billing services. These outcomes reflect a consistent approach to handling sensitive billing processes in maternal care.

By aligning with payer-specific rules and focusing on compliance, we have helped practices strengthen financial performance while maintaining adherence to medical necessity guidelines. Across multiple OBGYN groups, revenue cycle efficiency has demonstrated average year-over-year growth of 20–22%, accompanied by a client satisfaction rate exceeding 95%. This demonstrates our ability to support providers in a highly specialized and regulated billing area.