LCD : Transrectal Echography for Prostatic Disease (L1676)

LCD for Transrectal Echography for Prostatic Disease (L1676)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1676

LCD Title

Transrectal Echography for Prostatic Disease

Contractor's Determination Number

L1676

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 11/07/2004

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

Transrectal echographt requires special equipment to detect and map echoes of varying density from various organs and tumors. This policy addresses transrectal echography in the setting of prostatic disease. Transrectal echography of the prostate is medically necessary for:

1. Local staging of prostate cancer in patients with established diagnosis of prostate cancer.
2. Monitoring of response to therapy in patients with prostate cancer.
3. Measuring size/volume of prostate tissue prior to radiation therapy.
4. Evaluation of prostate for finding focci of possible cancerous tissue in an asymptomatic patient with normal Digital Rectal Examination (DRE) but PSA levels.
5. As an adjunct to guide needle biopsy of undiagnosed but palpable prostate nodule or tumors.

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)
14x	Non-Patient Laboratory Specimens

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

Radiologist

76872

ULTRASOUND, TRANSRECTAL;

Urologist

55700	BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH
76942	ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION

ICD-9 Codes that Support Medical Necessity

185	MALIGNANT NEOPLASM OF PROSTATE
198.5	SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
198.82	SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS
222.2	BENIGN NEOPLASM OF PROSTATE
233.4	CARCINOMA IN SITU OF PROSTATE
236.5	NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE
790.93	ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA]
V10.46	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE

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

If documentation is requested, submit:

History and Physical
Physician’s orders
Diagnosis/reason for tests being performed
Radiology reports
Itemized list of charges

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Other Carrier Policies

Advisory Committee Meeting Notes

This policy was presented and accepted 07/23/1996 by the Carrier Advisory Committee.

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

L1676b

Revision History Explanation

This LCD was converted from LMRP 036-96 on 3/30/2004

07/24/2002 Formatted

11/11/2000 added ICD-9 codes. Checked ICD-9 & CPT codes with 2001 Code Book.

11/07/2004 - The description for CPT/HCPCS code 76872 was changed in group 1

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

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

10/30/2007 - review without changes