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LA Medicare Part B  

SUBJECT: ULTRASOUND, PELVIC

POLICY NUMBER:

DESCRIPTION:

The following 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.

A complete study visualizes all of the structures or organs within the anatomic description of that study and the interpretation includes comments regarding the same.

A limited 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.

POLICY TYPE: Local medical necessity policy

HCPCS SECTION

& BENEFIT CATEGORY: Radiology; Diagnostic Ultrasound

HCPCS CODES©: 76856-76857

HCFA's NATIONAL POLICY:

- Title XVIII of the Social Security Act, section 1862 (a)(7). This section excludes physical examinations.

- Title 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.

INDICATIONS & LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

Ultrasound 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.

There 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 service.

NON-GESTATIONAL PELVIC ULTRASOUND

1. Uterus, 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, 626.0-626.9, 627.0-627.1)

2. Bladder: Ultrasound is 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)

3. Prostate: 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)

4. Pelvic 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)

5. Anatomic 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)

Not Indicated:

1. Pelvic 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 clinically effective.

2. Rectum: Rarely would ultrasound be indicated in rectal diseases with the exception of presacral or cul de sac abscesses.

3. Connective Tissue or Bony Tumors: Ultrasound is not indicated in routine diagnosis or follow-up of these diseases.

The following 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, 998.1-998.13, 998.5-998.59

II. GESTATIONAL ULTRASOUND

Routine 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:

1. Vaginal bleeding of undetermined etiology in pregnancy. (ICD-9-CM Codes 640.0-640.93)
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, 639.0-639.9)
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 placenta previa.
26. History of previous congenital anomaly.
27. Serial evaluation of fetal growth in multiple gestation.
28. Evaluation of fetal condition in late registrants for prenatal care.
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.

The following 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)

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

I. V10.41, 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, 998.5-998.59

II. V22.2, 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

REASONS FOR DENIAL:

There is no literature to support the efficacy of this procedure for any indications other than those listed above.

NONCOVERED ICD-9 CODES: All others not listed above.

SOURCES OF INFORMATION:

Physicians' Current Procedural Terminology (CPT)

CODING GUIDELINES:

76856 - Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete
76857 - Limited or follow-up (eg, for follicles)

This policy does not take precedence over the Correct Coding Initiative (CCI) and CCI does not interfere with Indications/Limitations or acceptable diagnoses specified.

DOCUMENTATION REQUIREMENTS:

Pelvic 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.

OTHER COMMENTS:

Medicare Providers' News LAB97-06, LA96-04 (G0050), LA96-03, LA96-02, LA95-07, LA95-04, LA94-10 and LA94-03

CAC NOTES:

This policy 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.

START DATE OF COMMENT PERIOD: 12/01/1993

START DATE OF NOTICE PERIOD: 11/1997
08/15/1996
05/31/1996
03/01/1996
11/30/1995
12/01/1995
06/01/1995
12/01/1994
06/01/1994

EFFECTIVE DATE: 07/01/1994

REVISION DATE:

REVISION NUMBER:
  

This page was last updated on 09/09/03


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