LCD : Lumbosacral Spine X-Ray (L1338)

LCD for Lumbosacral Spine X-Ray (L1338)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1338

LCD Title

Lumbosacral Spine X-Ray

Contractor's Determination Number

1338

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

Primary Geographic Jurisdiction

New Jersey
Tennessee

Secondary Geographic Jurisdiction

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming

Oversight Region

Region IV

Original Determination Effective Date

For services performed on or after 12/27/1996

Original Determination Ending Date

Revision Effective Date

For services performed on or after 07/27/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

A noninvasive diagnostic radiographic study to visualize bony and soft tissues of the lumbosacral spine.

If lumbosacral x-rays are needed in relationship to an illness, injury or specific symptomatology, diagnosis code must reflect medical necessity.

Coverage Topic

Diagnostic Tests and X-Rays

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

032X	Radiology diagnostic-general classification
033X	Radiology therapeutic-general classification
034X	Nuclear medicine-general classification
035X	Computed tomographic (CT) scan-general classification
040X	Other imaging services-general classification
061X	Magnetic resonance technology (MRT)-general classification

CPT/HCPCS Codes

72100	RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THREE VIEWS
72110	RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF FOUR VIEWS

ICD-9 Codes that Support Medical Necessity

170.2	MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
170.6	MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX
192.2	MALIGNANT NEOPLASM OF SPINAL CORD
198.5	SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
213.2	BENIGN NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX
213.6	BENIGN NEOPLASM OF PELVIC BONES SACRUM AND COCCYX
225.3	BENIGN NEOPLASM OF SPINAL CORD
238.0	NEOPLASM OF UNCERTAIN BEHAVIOR OF BONE AND ARTICULAR CARTILAGE
239.2	NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN
344.1	PARAPLEGIA
715.09	OSTEOARTHROSIS GENERALIZED INVOLVING MULTIPLE SITES
715.18	OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES
715.90	OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING UNSPECIFIED SITE
716.98	UNSPECIFIED ARTHROPATHY INVOLVING OTHER SPECIFIED SITES
720.0	ANKYLOSING SPONDYLITIS
720.2	SACROILIITIS NOT ELSEWHERE CLASSIFIED
721.3	LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY
721.42	SPONDYLOSIS WITH MYELOPATHY LUMBAR REGION
721.6	ANKYLOSING VERTEBRAL HYPEROSTOSIS
721.7	TRAUMATIC SPONDYLOPATHY
722.10	DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY
722.52	DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC
722.73	INTERVERTEBRAL DISC DISORDER WITH MYELOPATHY LUMBAR REGION
722.83	POSTLAMINECTOMY SYNDROME OF LUMBAR REGION
722.93	OTHER AND UNSPECIFIED DISC DISORDER OF LUMBAR REGION
724.02	SPINAL STENOSIS OF LUMBAR REGION
724.2	LUMBAGO
724.3	SCIATICA
724.4	THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED
724.5	BACKACHE UNSPECIFIED
724.6	DISORDERS OF SACRUM
730.08	ACUTE OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
730.18	CHRONIC OSTEOMYELITIS INVOLVING OTHER SPECIFIED SITES
732.0	JUVENILE OSTEOCHONDROSIS OF SPINE
732.8	OTHER SPECIFIED FORMS OF OSTEOCHONDROPATHY
733.00 - 733.09	OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS
733.13	PATHOLOGICAL FRACTURE OF VERTEBRAE
737.43	SCOLIOSIS ASSOCIATED WITH OTHER CONDITIONS
738.4	ACQUIRED SPONDYLOLISTHESIS
738.5	OTHER ACQUIRED DEFORMITY OF BACK OR SPINE
739.3	NONALLOPATHIC LESIONS OF LUMBAR REGION NOT ELSEWHERE CLASSIFIED
739.4	NONALLOPATHIC LESIONS OF SACRAL REGION NOT ELSEWHERE CLASSIFIED
741.03	SPINA BIFIDA LUMBAR REGION WITH HYDROCEPHALUS
741.93	SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS
756.11	CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION
756.12	SPONDYLOLISTHESIS CONGENITAL
756.14	HEMIVERTEBRA
756.15	FUSION OF SPINE (VERTEBRA) CONGENITAL
805.4	CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY
805.5	OPEN FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY
805.6	CLOSED FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY
805.7	OPEN FRACTURE OF SACRUM AND COCCYX WITHOUT SPINAL CORD INJURY
806.4	CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY
806.5	OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY
806.60	CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY
806.61	CLOSED FRACTURE OF SACRUM AND COCCYX WITH COMPLETE CAUDA EQUINA LESION
806.62	CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY
806.69	CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY
806.70 - 806.79	OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY
806.8	CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
806.9	OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY
839.20	CLOSED DISLOCATION LUMBAR VERTEBRA
839.30	OPEN DISLOCATION LUMBAR VERTEBRA
846.0	LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN
846.1	SACROILIAC (LIGAMENT) SPRAIN
846.2	SACROSPINATUS (LIGAMENT) SPRAIN
846.3	SACROTUBEROUS (LIGAMENT) SPRAIN
846.8	OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN
846.9	UNSPECIFIED SITE OF SACROILIAC REGION SPRAIN
953.2	INJURY TO LUMBAR NERVE ROOT
953.3	INJURY TO SACRAL NERVE ROOT
953.5	INJURY TO LUMBOSACRAL PLEXUS
958.3	POSTTRAUMATIC WOUND INFECTION NOT ELSEWHERE CLASSIFIED
998.2	ACCIDENTAL PUNCTURE OR LACERATION DURING A PROCEDURE NOT ELSEWHERE CLASSIFIED
998.51	INFECTED POSTOPERATIVE SEROMA
998.59	OTHER POSTOPERATIVE INFECTION
V45.4	POSTSURGICAL ARTHRODESIS STATUS

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentation Requirements

Medical documentation for all lumbosacral x-rays which are covered by Medicare is expected to indicate the clear and concise medical necessity within the patient's medical record, should review become necessary.

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier Policy

Medical tests

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period

11/27/1996

Revision History Number

1338a

Revision History Explanation

03/17/2004 ICD-9 codes added to the list of codes that support medical necessity.

07/24/2002 Formatted

11/02/2000 reviewed ICD-9 codes to insure compliance. No changes made.

This LCD was converted from an LMRP on 7/26/2005

7/2/2006 - The description for Bill code 14 was changed

2/18/2008 - The description for Bill code 21 was changed

3/20/2008 - Frequently Asked Questions removed from Appendices