policy reflects changes in the Carrier's existing policy which
was previously published in our March 1, 1996 Medicare Providers'
News (LA96-02). In accordance with the new 1998 ICD-9 updates,
the Carrier will allow ICD-9 code 756.71 for prune belly syndrome.
Also under VI. Vascular Structures, the verbiage "or
an abdominal bruit is appreciated" has been removed.
The rest of the policy remains unchanged.
guidelines do not represent a complete list of indications
for the utilization of ultrasound, but do represent an attempt
to aide an informed imaging selection based upon current literature
and equipment. Utilization of this procedure for diagnostic
purposes that clearly fall outside of these guidelines must
be documented in your records for review. It is quite obvious
that despite equipment improvements, ultrasound imaging limitations
remain - most important of which is the high level of operator
dependence. Consistent and accurate results can only be expected
if the examiner and the interpreter have adequate training
and maintain these skills through frequent use. Documentation
of this training and skill must be available
for review in a postpay audit.
study visualizes all of the structures or organs within the
anatomic description of that study and the interpretation
includes comments regarding the same.
study includes only a single quadrant or a possible single
diagnostic problem (i.e., cholecystitis, cyst of the liver,
or post void residual urine). Limited studies may be used
to reevaluate a problem after the initial interpretation has
been completed to clarify a finding of the initial study,
but this will require the patient's return to the office/department
and would not be considered as such if done during the primary
TYPE: Local Medical Review Policy
BENEFIT CATEGORY: Radiology; Diagnostic Ultrasound
XVIII of the Social Security Act, section 1862 (a)(7). This
section excludes physical examinations.
XVIII of the Social Security Act, section 1862 (a) (1) (A).
This section allows coverage and payment for only those services
are considered to be medically reasonable and necessary.
& LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:
FLUID DETECTION - Abdominal ultrasound is very useful in the
detection or confirmation of fluid in the abdominal cavity.
This is most commonly performed when there is clinical suspicion
of ascitic fluid. Other less common fluid collections include:
Hematoma, biloma and abdominal abscess (567._, 577.9, 864.01,
864.11, 865.0_, 865.1_).
(V71.1, 155.0-155.2, 197.7-197.8, 570, 571._, 572.0-572.8,
782.4, 794.8) -Ultrasound is often the first diagnostic test
used to evaluate the liver. The patient has generally had
a physical exam and preliminary laboratory tests to include
liver enzymes. Specific indications for ultrasound include:
exam reveals hepatomegaly or signs of portal hypertension,
such as ascites, spider angiomas, etc.
2. Abnormal blood tests: AST (SGOT), ALT (SGPT), GGT, alkaline
3. Suspicion of cirrhosis or diffuse hepatocellular disease.
There are other uncommon clinical situations where abdominal
ultrasound may be indicated. Usually, but not always, these
conditions may be associated with abnormal physical findings
or lab tests.
4. Suspected abscess, including pyogenic or amebic
5. Evaluation of neoplasms or liver masses
6. Suspected metastatic liver disease
7. Liver trauma
8. Diagnosis and follow-up of hepatic cysts
TRACT (V71.1, 156._, 574._, 575._, 576._, 793.3) -The patient
undergoing abdominal ultrasound for a suspected abnormality
of the gallbladder or biliary tract will have had prior history
taken, physical exam performed, and lab tests to include liver
enzymes and bilirubin. This history may reveal symptoms typical
of gallstones. Biliary colic is characteristically a severe
pain in the right upper quadrant or epigastrium. It is constant
in intensity for a duration of 30 minutes to two hours. It
must always be remembered that clinical presentations may
be unusual or atypical, especially in the elderly patient.
indications for ultrasound are:
of jaundice found on physical exam
2. Suspected gallbladder stones (history of biliary colic)
3. Suspected cholecystitis, including acalculous cholecystitis
(prior physical exam performed may include upper abdominal
tenderness and fever)
4. Suspected gallbladder neoplasms, including follow-up of
benign lesions such as polyps
5. Evaluation of the common bile duct. Abnormalities of the
common bile duct, such as stones or obstructive symptoms (i.e.,
abdominal pain, fever, chills or jaundice).
6. Suspected biliary neoplasm
(V71.1, 155, 157._, 577._, 863.8, 863.9) - When abdominal
ultrasound is being used to evaluate the pancreas, the patient
will have had prior history, physical exam and lab tests to
include serum amylase.
of acute pancreatitis
2. Suspected complications of pancreatitis, including abscess
3. Chronic pancreatitis
4. Pancreatic trauma
5. Pancreatic neoplasm, including adenocarcinoma, cystadenoma,
islet cell tumors
OF THE GASTROINTESTINAL TRACT (159, 211._, 540._) If physical
examination of the patient reveals an abdominal mass, ultrasound
may be helpful to clarify the origin of the mass, as well
as confirm its presence.
are several inflammatory conditions of the GI tract where
ultrasound is occasionally helpful (Crohn's disease, appendicitis,
diverticulitis). Usually these diagnoses are made utilizing
other clinical methods and if ultrasound is being used, the
case is likely an atypical presentation and its use should
be justified. Physical findings may include fever and localized
abdominal tenderness. A leukocytosis may be present.
STRUCTURES (441.02, 441.3, 441.4, 442.84, 452) - Ultrasound
is useful in the suspicion of dissecting aortic aneurysms.
Physical exam may reveal a pulsatile mass in the abdomen.
aneurysm is diagnosed, ultrasound is often used to follow
the size if the patient does not undergo initial surgery.
intervals are acceptable between studies. If more frequent
exams are necessary, documentation should be on hand for review.
vascular studies are rarely necessary but may be utilized
in vena cava filter location and portal vein evaluation for
patency in advanced liver disease.
OF INTRA-ABDOMINAL CAVITY AND WALL LESIONS (567._, 756.71)
- Utilized as a guide for aspiration or biopsy of intra-abdominal
lesions. Prior physical examination of the patient reveals
a suspected lesion within the abdominal wall.
SPLEEN - Ultrasound may be helpful in the evaluation of suspected
disorders of the spleen. The patient will have undergone prior
history and physical examination. (ICD-9-CM codes 289.5_,
759.0, 902.23, 902.34)
of focal lesions
2. Suspected acute splenic infarction
3. Splenic trauma
ULTRASOUND FOR THE INDICATION OF ABDOMINAL PAIN WILL BE CLOSELY
MONITORED FOR ABERRANT USAGE. (789.0_, 789.1, 789.2, 789.3_,
789.4_, 789.5, 789.6_, 789.9)
CODES THAT SUPPORT MEDICAL NECESSITY:
155.0-155.2, 156.0-156.9, 157.0-157.9, 159.0-159.9, 195.2,
196.2, 197.7-197.8, 211.0-211.9, 228.04, 289.50-289.59, 441.02,
441.3, 441.4, 442.84, 452, 540.0-540.9, 567.0-567.9, 570,
571.0-571.9, 572.0-572.8, 574.0-574.91, 575.0-575.9, 576.0-576.9,
577.0-577.9, 756.71 (10/1997), 759.0, 782.4, 789.00-789.09,
789.1, 789.2, 789.30-789.39, 789.40-789.49, 789.5, 789.60-789.69,
789.9, 790.5, 793.3, 794.8, 863.8, 863.9, 864.01, 864.11,
865.00-856.09, 865.10-865.19, 902.23, 902.34, 998.51-998.59
ICD-9 codes not mentioned above will be denied.
is no literature to support the efficacy of this procedure
for any indications other than those listed above.
ICD-9 CODES: All others not mentioned above.
Current Procedural Terminology (CPT);
was developed in conjunction with our Medical Services Review
Committee (02/1994) which consist of primary care and relative
specialties (LAMSRC Item 94-6).
- Echography, abdominal, B-scan and/or real time with image
76705 - Limited (eg, single organ, quadrant, follow-up
does not take precedence over the Correct Coding Initiative
(CCI) and CCI does not interfere with Indications/Limitations
or acceptable diagnoses specified.
COMMENTS: Medicare Providers' News LAB97-06, LA96-02,
LA95-07, LA95-04, LA94-10, and LA94-03
does not reflect the sole opinion of the carrier or Carrier
Medical Director. Although the final decision rests with the
carrier, this policy was developed in cooperation with the
Carrier Advisory Committee (12/1993), which includes representatives
from radiology, gastroenterology, OB/GYN, and urology.
DATE OF COMMENT PERIOD: 12/01/1993
DATE OF NOTICE PERIOD: 11/1997
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