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2012 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 8. Physician : 8.2 Services, Benefits, Limitations, and Prior Authorization : 8.2.46 Obstetrics and Prenatal Care : Obstetric Ultrasound
Ultrasound of the pregnant uterus is a benefit of Texas Medicaid when medically indicated. Ultrasound may be indicated for suspected genetic defects, high risk pregnancy, and fetal growth retardation.
The following procedure codes for ultrasound of the pregnant uterus are limited to a total of three per pregnancy:
The limit of three obstetric ultrasounds per pregnancy does not apply to obstetric ultrasound procedures that are rendered in the emergency room, outpatient observation, or inpatient hospital setting. Obstetric ultrasounds provided in the emergency department must be submitted with modifier U6 when submitted on the professional claim form in order to be considered for payment. Obstetric ultrasounds provided in the emergency department or during a hospital observation stay must be submitted with the appropriate corresponding emergency services or hospital observation revenue code in order to be considered for payment.
The initial three claims paid for obstetric ultrasounds do not require prior authorization. Any obstetric ultrasound claims submitted with or without prior authorization for the initial three will count toward the three-per-pregnancy limit. If it is medically necessary to perform more than three obstetrical ultrasounds on a client during one pregnancy, the provider must request prior authorization with documentation of medical necessity using the Form MD.8, “Obstetric Ultrasound Prior Authorization Request Form” in this handbook.
Texas Medicaid follows the ACOG indications for sonography. First trimester ultrasounds may be medically necessary for, but are not limited to, the following reasons:
Second and third trimester ultrasounds may be medically necessary for the following reasons:
The Obstetric Ultrasound Prior Authorization Request Form must be completed, signed, dated, and maintained in the client’s medical record by the provider ordering the test, regardless of the method of request for authorization. A physician, nurse practitioner (NP), clinical nurse specialist (CNS), certified nurse midwife (CNM), or physician assistant (PA) may sign the Obstetric Ultrasound Prior Authorization Request Form. Residents may order obstetric ultrasounds; however, the attending physician must sign the authorization form and include the group or supervising provider identifier on the form.
The provider’s signature must be current, unaltered, original, and handwritten. A computerized or stamped signature or date will not be accepted.
The form must include information related to medical necessity of the test including all of the following:
Additional documentation to support medical necessity may include any of the following:
When requesting retroactive authorization, providers must submit the request no later than 14 calendar days beginning the day after the study is completed.
Providers can submit requests for prior authorization or retroactive authorization by phone, by fax, online, or by mailing to:
Texas Medicaid & Healthcare Partnership
Inpatient/Outpatient Prior Authorization
12357-B Riata Trace Parkway Ste. 150
Austin, TX 78727
Reimbursement for obstetric ultrasounds may be considered on appeal when submitted with documentation that indicates any one of the following:
Only one appeal will be considered per client for the same provider. Providers must obtain prior authorization for any additional obstetric ultrasounds performed after the appealed service.
The following procedure codes must be billed together:
The following table includes procedure codes that will be denied as part of another procedure when billed on the same date of service by the same provider:

Texas Medicaid & Healthcare Partnership
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