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., ovarian disease, unilateral study.
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 encounter.
TYPE: Local medical necessity 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:
of the pelvis is considered medically necessary to aid in
the diagnosis and treatment of disorders of the anatomical
pelvis. It is a covered procedure when used to evaluate abnormal
physical findings, when used to evaluate a patient with genital
cancer, or when the patient's condition makes bimanual pelvic
examination inadequate to evaluate the pelvis. The physical
exam should include a description of the lower abdomen, rectum,
and a bimanual pelvic exam. Utilization without the above
will be considered as not being medically necessary unless
there are extenuating circumstances precluding these examinations.
is broad use of this modality in the diagnosis of pelvic pain.
This is a covered indication after standard abdominal, pelvic,
and rectal exams have failed to identify the source of the
problem. Routine use in all patients with pelvic pain is not
considered medically necessary, therefore, the patient's record
must support the medical necessity. Ultrasound is considered
of prime time importance in the evaluation of pelvic masses.
It is not considered of primary importance in the evaluation
of pelvic nodal structures. Routine use of ultrasound for
cancer screening in asymptomatic patients is not a covered
Tubes and Ovaries: Ultrasound is considered of prime importance
in diagnosing disorders of these organs when an adequate bi-manual
exam has not clearly defined the problem. Use of pelvic ultrasound
in routine myomas is not considered medically necessary, but
can be used in complicated or questionable cases and documentation
in the chart must contain the medical necessity. Routine use
when endocervical or endometrial biopsy is contemplated is
also not indicated. Tumors and inflammatory masses of the
tubes, ovaries, and broad ligaments are considered covered
items when routine physical exam is not adequate for diagnosis.
(ICD-9-CM Codes V71.1, 179, 180-180.1, 180.8-180.9, 181, 182.0-182.1,
182.8, 183.0-183.9, 218.0-218.9, 219.0-219.9, 220, 221.0-221.1,
221.9, 233.2, 233.1, 256.0-256.9, 614.0-614.9, 615.0-615.9,
617.0-617.9, 620.0-620.9, 621.0-621.9, 625.0, 625.2, 625.3,
considered a primary tool in evaluating
post void residual urine (local code Y6857 (prior 1/1/96;
G0050 after 1/1/96), but is not considered the primary
tool in the evaluation of hematuria and bladder tumors. It
may be of some value in bladder diverticula. The diagnosis
of primary cystitis would not be covered for the utilization
of this modality. (ICD-9-CM Codes 236.0-236.3, 236.7-236.99,
594.0, 596.3, 753.8)
Evaluation of the prostate is primarily done transrectally
and has been addressed in previous newsletters. (ICD-9-CM
Codes 185, 236.5, 600, 601.0-601.9)
Vascular Structures: Ultrasound is valuable in diagnosing
and sizing aneurysms of the arterial system and follow-up
should be considered medically necessary if done on a six
month basis. Venous evaluations are not considered medically
necessary. (ICD-9-CM Codes 442.2, 451.81)
Cul-de-sac: Evaluation of masses of the cul-de-sac or fluid
collections are considered covered services for pelvic ultrasound.
(ICD-9-CM Code 619.8)
nodal: Pelvic nodal evaluations are done primarily with CT
scans and repeat ultrasounds are of little value. Follow-up
of prostatic nodal progression for staging has not been proved
Rarely would ultrasound be indicated in rectal diseases with
the exception of presacral or cul de sac abscesses.
Tissue or Bony Tumors: Ultrasound is not indicated in routine
diagnosis or follow-up of these diseases.
are additional ICD-9-CM codes which could be utilized for
non-gestational pelvic ultrasound: V10.41, V10.43, V10.48
(10/1998), V13.2, V13.61 (10/1998), V13.69 (10/1998), 158.0-158.9,
186.0-186.9, 187.9, 195.3, 222.0-222.9, 568.81, 568.89, 603.0-603.9,
604.0-604.99, 608.0-608.9, 752.0-752.9, 756.71 (10/1997),
787.3, 789.03-789.04, 789.43-789.44, 789.5, 789.63-789.64,
use of ultrasound in uncomplicated pregnancies is not felt
to be medically necessary and will not be a covered service.
Covered services in pregnancy would be related to conditions
as outlined below:
bleeding of undetermined etiology in pregnancy. (ICD-9-CM
2. Evaluation of fetal growth when the patient has an identified
etiology for uteroplacental insufficiency (chronic systemic
diseases such as diabetes, chronic hypertension, cardiac disease,
renal disease, pregnancy induced hypertension, etc.) (ICD-9-CM
Codes 642.0-642.94, 648.0-648.94)
3. Estimation of gestational age for patients with clinically
significant uncertain delivery dates, or verification of dates
for patients who are to undergo scheduled elective repeat
cesarean delivery, indicated induction of labor, or other
elective termination of pregnancy. (ICD-9-CM Code 632)
4. Determination of fetal presentation when presenting part
cannot be adequately determined in labor or when the fetal
presentation is abnormal within three weeks of the patient's
estimated date of confinement (EDC or due date).
5. Suspected multiple gestation based on detection of more
than one fetal heartbeat pattern, or fundal height larger
than expected for dates, and/or prior use of fertility drugs.
6. Adjunct to amniocentesis.
7. Significant uterine size/clinical dates discrepancy (macrosomnia
or intrauterine growth retardation)
8. Pelvic mass detected clinically. (ICD-9-CM Code 789.33-789.35)
9. Suspected hydatidiform mole on the basis of clinical signs
of hypertension, proteinuria, and/or the presence of ovarian
cysts felt on pelvic examination, or failure to detect fetal
heart tones with a Doppler ultrasound device after twelve
weeks. (ICD-9-CM Code 236.1 or 630)
10. Adjunct to cervical cerclage placement.
11. Suspected ectopic pregnancy or when pregnancy occurs after
tuboplasty or prior ectopic gestation. (ICD-9-CM Codes 633.0-633.9,
12. Adjunct to special procedures such as fetoscopy, intrauterine
transfusion, shunt placement, in-vitro fertilization, embryo
transfer, or chorionic villi sampling.
13. Suspected fetal death.
14. Suspected uterine abnormality.
15. Intrauterine contraceptive device localization.
16. Ovarian follicle development surveillance.
17. Biophysical examination for fetal well-being for fetus
at risk of compromise.
18. Observation of intrapartum events (e.g., version and extraction
of second twin, manual removal of placenta, and so forth).
(ICD-9-CM Code 662.3-662.33)
19. Suspected polyhydramnios or oligohydramnios. (ICD-9-CM
Codes 657.0-657.03, 658.0-658.93, 761.2)
20. Suspected abruptio placentae. (ICD-9-CM Codes 641.0-641.93)
21. Adjunct to external version from breech to vertex presentation.
22. Estimation of fetal weight and/or presentation in premature
rupture of membranes and/or premature labor.
23. Abnormal serum alpha-fetoprotein value for clinical gestational
age when drawn.
24. Known or suspected fetal abnormality. (ICD-9-CM Codes
651.0-652.93, 652.0-652.93, 655.0-655.93)
25. Follow-up evaluation of placenta location for identified
26. History of previous congenital anomaly.
27. Serial evaluation of fetal growth in multiple gestation.
28. Evaluation of fetal condition in late registrants for
29. Evaluation of post-maturity.
30. History of cervical incompetence. (ICD-9-CM Codes 654.0-654.94)
31. Habitual abortion. (ICD-9-CM Codes 634.0-634.99, 761.8)
32. Evaluation of neural tube defect.
33. Evaluation of fetal arrhythmias.
are additional ICD-9-CM codes which could be utilized for
gestational pelvic ultrasound: V22.2, V23.81-V23.89 (10/1998),
631, 643.0-643.93, 644.0-644.21, 645.0-645.03, 646.0-646.93,
656.0-656.93, 659.0-659.93, 660.0-660.93, 663.0-663.93, 665.0-665.11,
665.7-665.74, 667.0-667.14, 763.8-763.89 (10/1998)
CODES THAT SUPPORT MEDICAL NECESSITY:
V10.43, V10.48 (10/1998), V13.2, V13.61 (10/1998), V13.69
(10/1998), V71.1, 158.0-158.9, 179, 180-180.9, 181, 182.0-182.8,
183.0-183.9, 185, 186.0-186.9, 187.9, 195.3, 218.0-218.9,
219.0-219.9, 220, 221.0-221.1, 221.9, 222.0-222.9, 233.1-233.2,
236.0-236.3, 236.5, 236.7-236.99, 256.0-256.9, 442.2, 451.81,
568.81, 568.89, 594.0, 596.3, 600, 601.0-601.9, 603.0-603.9,
604.0-604.99, 608.0-608.9, 614.0-614.9, 615.0-615.9, 617.0-617.9,
619.8, 620.0-620.9, 621.0-621.9, 625.0, 625.2-625.3, 626.0-626.9,
627.0-627.1,752.0-752.9, 753.8, 756.71 (10/1997), 787.3, 789.03-789.04,
789.33-789.35, 789.43-789.44, 789.5, 789.63-789.64, 998.1-998.13,
V23.81-V23.89 (10/1998), 236.1, 630, 631, 632, 633.0-633.9,
634.0-634.99, 639.0-639.9, 640.0-640.93, 641.0-641.93, 642.0-642.94,
643.0-643.93, 644.0-644.21, 645.0-645.03, 646.0-646.93, 648.0-648.94,
651.0-651.03, 652.0-652.93, 654.0-654.94, 655.0-655.93, 656.0-656.93,
657.0-657.03, 658.0-658.93, 659.0-659.93, 660.0-660.93, 662.3-662.33,
663.0-663.93, 665.0-665.11, 665.7-665.74, 667.0-667.14, 761.2,
761.8, 763.8-763.89 (10/1998), 789.33-789.35
is no literature to support the efficacy of this procedure
for any indications other than those listed above.
ICD-9 CODES: All others not listed above.
Current Procedural Terminology (CPT)
- Echography, pelvic (nonobstetric), B-scan and/or real time
with image documentation; complete
76857 - Limited or follow-up (eg, for follicles)
does not take precedence over the Correct Coding Initiative
(CCI) and CCI does not interfere with Indications/Limitations
or acceptable diagnoses specified.
ultrasound is not considered medically necessary if done without
adequate documentation in the history and physical exam of
indications for the study, along with the supporting lab data.
Providers' News LAB97-06, LA96-04 (G0050), LA96-03, 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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