Home Uterine Activity Monitoring Form

Home Uterine Activity Monitoring

Last Review Date: April 10, 2026  
Number: MG.MM.ME.32cC5

Definitions
Preterm labor (PTL) (also referred to as premature labor) — labor onset from after 20 weeks gestation to less than

37. Preterm labor risks include but are not limited to the following:
38. Previous preterm birth
39. Multiple gestation pregnancy (twins, triplets or more)
40. Presence of cervical or uterine abnormalities
41. Past history of preterm labor or preterm labor during current pregnancy.
42. Problems with the uterus, cervix or placenta.
43. Smoking cigarettes, drinking alcohol or using illicit drugs
44. Some infections, particularly of the amniotic fluid and lower genital tract
45. Some chronic conditions, such as high blood pressure and diabetes
46. Being underweight or obese before pregnancy
47. Stressful life events, such as the death of a loved one or domestic violence
48. Multiple miscarriages or abortions
49. Presence of bacterial vaginosis, trichomonaisis, or sexually transmitted infections
50. In vitro fertilization pregnancy

51. Short interpregnancy interval < 6 months

    Preterm birth — birth prior to 37 weeks gestation. Home uterine activity monitor (HUAM) — an electronic system consisting of a tocotransducer, recorder, modem and a data receive/process/display computer/monitor, which measures and then transmits uterine contraction data to a remote location for the purpose of PTL-detection.

Guideline

Revision History Apr. 28, 2020 Added that EmblemHealth considers home uterine activity monitoring (HUAM) for twin gestation, or as otherwise prescribed, to be medically necessary throughout the duration of the coronavirus 2019 (COVID-19) state of emergency.
Added clarification language that more definitively communicates the definition of high risk pregnancies. Applicable Procedure Codes 99500 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring S9001 Home uterine monitor with or without associated nursing services

Applicable ICD-10 Diagnosis Codes O09.211 Supervision of pregnancy with history of pre-term labor, first trimester O09.212 Supervision of pregnancy with history of pre-term labor, second trimester O09.213 Supervision of pregnancy with history of pre-term labor, third trimester O09.219 Supervision of pregnancy with history of pre-term labor, unspecified trimester O26.872 Cervical shortening, second trimester O26.873 Cervical shortening, third trimester O26.879 Cervical shortening, unspecified trimester O30.101 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.102 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester O30.103 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.109 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.111 Triplet pregnancy with two or more monochorionic fetuses, first trimester O30.112 Triplet pregnancy with two or more monochorionic fetuses, second trimester

O30.113 Triplet pregnancy with two or more monochorionic fetuses, third trimester O30.119 Triplet pregnancy with two or more monochorionic fetuses, unspecified trimester O30.121 Triplet pregnancy with two or more monoamniotic fetuses, first trimester O30.122 Triplet pregnancy with two or more monoamniotic fetuses, second trimester O30.123 Triplet pregnancy with two or more monoamniotic fetuses, third trimester O30.129 Triplet pregnancy with two or more monoamniotic fetuses, unspecified trimester O30.131 Triplet pregnancy, trichorionic/triamniotic, first trimester
O30.132 Triplet pregnancy, trichorionic/triamniotic, second trimester
O30.133 Triplet pregnancy, trichorionic/triamniotic, third trimester
O30.139 Triplet pregnancy, trichorionic/triamniotic, unspecified trimester
O30.191 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester O30.192 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester O30.193 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester O30.199 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.201 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.202 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimester O30.203 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.209 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.211 Quadruplet pregnancy with two or more monochorionic fetuses, first trimester O30.212 Quadruplet pregnancy with two or more monochorionic fetuses, second trimester O30.213 Quadruplet pregnancy with two or more monochorionic fetuses, third trimester O30.219 Quadruplet pregnancy with two or more monochorionic fetuses, unspecified trimester O30.221 Quadruplet pregnancy with two or more monoamniotic fetuses, first trimester O30.222 Quadruplet pregnancy with two or more monoamniotic fetuses, second trimester O30.223 Quadruplet pregnancy with two or more monoamniotic fetuses, third trimester O30.229 Quadruplet pregnancy with two or more monoamniotic fetuses, unspecified trimester O30.231 Quadruplet pregnancy, quadrachorionic/quadra-amniotic, first trimester
O30.232 Quadruplet pregnancy, quadrachorionic/quadra-amniotic, second trimester
O30.233 Quadruplet pregnancy, quadrachorionic/quadra-amniotic, third trimester
O30.239 Quadruplet pregnancy, quadrachorionic/quadra-amniotic, unspecified trimester
O30.291 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimester O30.292 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimester O30.293 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimester O30.299 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.801 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, first trimester O30.802 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, second trimester

O30.803 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.809 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O30.811 Other specified multiple gestation with two or more monochorionic fetuses, first trimester O30.812 Other specified multiple gestation with two or more monochorionic fetuses, second trimester O30.813 Other specified multiple gestation with two or more monochorionic fetuses, third trimester O30.819 Other specified multiple gestation with two or more monochorionic fetuses, unspecified trimester O30.821 Other specified multiple gestation with two or more monoamniotic fetuses, first trimester O30.822 Other specified multiple gestation with two or more monoamniotic fetuses, second trimester O30.823 Other specified multiple gestation with two or more monoamniotic fetuses, third trimester O30.829 Other specified multiple gestation with two or more monoamniotic fetuses, unspecified trimester O30.831 Other specified multiple gestation, number of chorions and amnions are both equal to the number of fetuses, first trimester
O30.832 Other specified multiple gestation, number of chorions and amnions are both equal to the number of fetuses, second trimester
O30.833 Other specified multiple gestation, number of chorions and amnions are both equal to the number of fetuses, third trimester
O30.839 Other specified multiple gestation, number of chorions and amnions are both equal to the number of fetuses, unspecified trimester
O30.891 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, first trimester O30.892 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, second trimester O30.893 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, third trimester O30.899 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, unspecified trimester O30.90 Multiple gestation, unspecified, unspecified trimester O30.91 Multiple gestation, unspecified, first trimester O30.92 Multiple gestation, unspecified, second trimester O30.93 Multiple gestation, unspecified, third trimester O31.10x0 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, not applicable or unspecified O31.10x1 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 1 O31.10x2 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 2 O31.10x3 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 3 O31.10x4 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 4 O31.10x5 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, fetus 5 O31.10x9 Continuing pregnancy after spontaneous abortion of one fetus or more, unspecified trimester, other fetus O31.11x0 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, not applicable or unspecified O31.11x1 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 1

O31.11x2 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 2 O31.11x3 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 3 O31.11x4 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 4 O31.11x5 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 5 O31.11x9 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, other fetus O31.12x0 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, not applicable or unspecified O31.12x1 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 1 O31.12x2 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 2 O31.12x3 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 3 O31.12x4 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 4 O31.12x5 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 5 O31.12x9 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, other fetus O31.13x0 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, not applicable or unspecified O31.13x1 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 1 O31.13x2 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 2 O31.13x3 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 3 O31.13x4 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 4 O31.13x5 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 5 O31.13x9 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, other fetus O31.20x0 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, not applicable or unspecified O31.20x1 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 1 O31.20x2 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 2 O31.20x3 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 3 O31.20x4 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 4 O31.20x5 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, fetus 5 O31.20x9 Continuing pregnancy after intrauterine death of one fetus or more, unspecified trimester, other fetus O31.21x0 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, not applicable or unspecified O31.21x1 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 1 O31.21x2 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 2 O31.21x3 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 3 O31.21x4 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 4 O31.21x5 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 5 O31.21x9 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, other fetus O31.22x0 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, not applicable or unspecified O31.22x1 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 1 O31.22x2 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 2 O31.22x3 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 3

O31.22x4 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 4 O31.22x5 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 5 O31.22x9 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, other fetus O31.23x0 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, not applicable or unspecified O31.23x1 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 1 O31.23x2 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 2 O31.23x3 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 3 O31.23x4 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 4 O31.23x5 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 5 O31.23x9 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, other fetus O31.8X10 Other complications specific to multiple gestation, first trimester, not applicable or unspecified O31.8X11 Other complications specific to multiple gestation, first trimester, fetus 1 O31.8X12 Other complications specific to multiple gestation, first trimester, fetus 2 O31.8X13 Other complications specific to multiple gestation, first trimester, fetus 3 O31.8X14 Other complications specific to multiple gestation, first trimester, fetus 4 O31.8X15 Other complications specific to multiple gestation, first trimester, fetus 5 O31.8X19 Other complications specific to multiple gestation, first trimester, other fetus O31.8X20 Other complications specific to multiple gestation, second trimester, not applicable or unspecified O31.8X21 Other complications specific to multiple gestation, second trimester, fetus 1 O31.8X22 Other complications specific to multiple gestation, second trimester, fetus 2 O31.8X23 Other complications specific to multiple gestation, second trimester, fetus 3 O31.8X24 Other complications specific to multiple gestation, second trimester, fetus 4 O31.8X25 Other complications specific to multiple gestation, second trimester, fetus 5 O31.8X29 Other complications specific to multiple gestation, second trimester, other fetus O31.8X30 Other complications specific to multiple gestation, third trimester, not applicable or unspecified O31.8X31 Other complications specific to multiple gestation, third trimester, fetus 1 O31.8X32 Other complications specific to multiple gestation, third trimester, fetus 2 O31.8X33 Other complications specific to multiple gestation, third trimester, fetus 3 O31.8X34 Other complications specific to multiple gestation, third trimester, fetus 4 O31.8X35 Other complications specific to multiple gestation, third trimester, fetus 5 O31.8X39 Other complications specific to multiple gestation, third trimester, other fetus O31.8X90 Other complications specific to multiple gestation, unspecified trimester, not applicable or unspecified O31.8X91 Other complications specific to multiple gestation, unspecified trimester, fetus 1 O31.8X92 Other complications specific to multiple gestation, unspecified trimester, fetus 2 O31.8X93 Other complications specific to multiple gestation, unspecified trimester, fetus 3 O31.8X94 Other complications specific to multiple gestation, unspecified trimester, fetus 4 O31.8X95 Other complications specific to multiple gestation, unspecified trimester, fetus 5 O31.8X99 Other complications specific to multiple gestation, unspecified trimester, other fetus

O32.9xx0 Maternal care for malpresentation of fetus, unspecified, not applicable or unspecified O34.30 Maternal care for cervical incompetence, unspecified trimester O34.31 Maternal care for cervical incompetence, first trimester O34.32 Maternal care for cervical incompetence, second trimester O34.33 Maternal care for cervical incompetence, third trimester O60.00 Preterm labor without delivery, unspecified trimester O60.02 Preterm labor without delivery, second trimester O60.03 Preterm labor without delivery, third trimester Z87.51 Personal history of pre-term labor