LCD : Pelvic Echography for Prostate Follow-up (L1412)

LCD for Pelvic Echography for Prostate Follow-up (L1412)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1412

LCD Title

Pelvic Echography for Prostate Follow-up

Contractor's Determination Number

1412

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 08/04/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Ultrasonography is a noninvasive procedure using high frequency sound waves (beyond range of human hearing) to examine internal structure of body.

Urinary tract imaging is not recommended in the routine evaluation of men with prostatism unless they have one or more of the following medically necessary indications: hematuria, urinary tract infection, renal insufficiency, history of urolithiasis, history of urinary tract surgery or surgery is planned. A diagnosis of benign prostatic hypertrophy (BPH) (600) does not indicate the medical necessity of an ultrasound for determination of bladder residual volume. The patient must have other factors which indicate the need for testing. A routine ultrasound for the purpose of determining residual volume is not a covered service when performed in the place of a routine catheterization. Routine catheterizations are not separately billable. If the patient has medical indications for a complete study, the ICD-9 diagnosis code must indicate the medical necessity and the patient’s medical record must contain adequate documentation.

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)

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
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

76856	ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE
76857	ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES)

ICD-9 Codes that Support Medical Necessity

185	MALIGNANT NEOPLASM OF PROSTATE
586	RENAL FAILURE UNSPECIFIED
591	HYDRONEPHROSIS
595.9	CYSTITIS UNSPECIFIED
596.0	BLADDER NECK OBSTRUCTION
596.3	DIVERTICULUM OF BLADDER
596.6	RUPTURE OF BLADDER NONTRAUMATIC
598.2	POSTOPERATIVE URETHRAL STRICTURE
599.60	URINARY OBSTRUCTION, UNSPECIFIED
599.69	URINARY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED
599.7	HEMATURIA

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 Medicare covered pelvic ultrasounds is expected to clearly and concisely indicate the medical necessity for the procedure within the patient's medical record, should chart review become necessary. If documentation is requested, submit:

History and Physical
M.D. orders/progress notes
Diagnosis/Reason for test or procedure
Test/procedure report
Itemization of charges

Appendices

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier Policy

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

1412a

Revision History Explanation

07/24/2002 Formatted

11/7/2000-Reviewed codes with ICD-9 2001 & CPT code book. No changes made.

This LCD was converted from an LMRP on 8/3/2005

09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update.

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

11/18/2006 - The description for CPT/HCPCS code 76856 was changed in group 1
11/18/2006 - The description for CPT/HCPCS code 76857 was changed in group 1

10/05/2007 - Frequently Asked Questions restored to Appendices.