J160 – Diagnostic ultrasound - high risk pregnancy or complications of pregnancy
OHIP Cardio-Thoracic Surgery Code — DIAGNOSTIC ULTRASOUND · Schedule of Benefits
Complete ultrasound for high risk pregnancy or complications of pregnancy. This service is composed of two parts: - Technical Component (H): $48.75 - Professional Component (P): $32.25 The technical component (H) is for the performance of the ultrasound scan itself, and the professional component (P) is for the physician's interpretation and report. According to the General Preamble (), the technical component may be ineligible for payment if rendered to a hospital in-patient or a patient who is subsequently admitted to the hospital within 24 hours for the same condition.
When to Use
- Use J160 for a comprehensive assessment of a high-risk pregnancy, such as suspected intrauterine growth restriction (IUGR) or placental insufficiency, which exceeds the scope of a routine J158 scan.
- Use J160 when managing specific pregnancy complications like severe pre-eclampsia or maternal alloimmunization that require detailed fetal surveillance beyond standard prenatal imaging.
Common Pitfalls
- Billing J160 on the same day as J168 will result in a rejection, as these codes are mutually exclusive for pregnancy-related ultrasound services.
- Failing to include the add-on code J166 when performing a high-risk scan on a multiple gestation pregnancy results in significant under-billing for the additional fetuses.
- Attempting to bill the technical component (H) for patients who are admitted to the hospital within 24 hours of the service, which violates the General Preamble rules regarding hospital in-patient services.
Billing Tips
- Always append J167 when performing Doppler studies of the middle cerebral artery or ductus venosus for IUGR or fetal anemia, as this is a distinct, billable add-on to the base J160 fee.
- Ensure the clinical indication for 'high risk' is explicitly stated in the diagnostic code or report to avoid manual review or audit triggers for this higher-valued ultrasound code.
Effective: April 1, 2025
G. Diagnostic Ultrasound
DIAGNOSTIC ULTRASOUND
Diagnostic
Diagnostic Ultrasound
The medical record must document the indication for the ultrasound, such as the high-risk nature of the pregnancy or the specific complication(s) being assessed.
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