HealthNow UMD
Article -- Coding Guidelines

Contractor Name
HealthNow

Contractor Number
00801

Contractor Type
Carrier

Article Database ID Number
A22852

Contractor Determination Number
R-96-3 (11)

Article Type
Detailed Article

Article Title
Abdominal Ultrasound Procedures - 4

Is the AMA CPT / ADA CDT Copyright Statement Required?
Yes

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. CDT-4 codes and descriptions are (C) 2002, 2004 American Dental Association. All rights reserved.

Primary Geographic Jurisdiction
Upstate New York

Article Publication Date
09/15/2004

Article Beginning Effective Date
10/01/2003

Article Ending Effective Date
10/01/2007

Coding Guidelines

   1.  The guidelines of the Correct Coding Initiative (CCI) supersede all
       coding instructions in this LCD.

   2.  The diagnosis code(s) must best describe the patient's condition for
       which the service was performed.

   3.  Abdominal ultrasound includes all the upper abdominal organs from the
       xiphoid to the umbilicus (gallbladder, liver, pancreas and spleen).
       Therefore, multiple organs of interest should be coded as a complete
       study (76700).

   4.  Retroperitoneal ultrasound 76770/76775 is payable in addition to
       abdominal ultrasound when performed on the same day.

   5.  Bilateral studies, performed on the same day should be paid as one
       complete study (CPT 76700) only.

   6.  Billed services for which the provider expects a medical necessity
       denial should have either the GA (with signed ABN) or GZ (without
       signed ABN) modifier attached to the code. If the service is
       statutorily non-covered or without benefit category, use the GY
       modifier instead.

   7.  The name and UPIN number of the referring/ordering physician or
       qualified non-physician practitioner must be reported in Items 17 and
       17a of the CMS-1500 form, or NPI (when effective) in item 17b, or in
       the electronic equivalent, when submitting electronically.

   8.  Abdominal ultrasounds are payable in the following places of service:

       For the global and technical component (modifier TC): office (11),
       home (12),  assisted living facility (13), group home (14), mobile
       unit (15), nursing facility for patients not in a Part A stay (32),
       custodial care facility (33),  independent clinic (49), community
       mental health center (53) and state or local public health clinic
       (71).

       For the professional component (modifier 26): office (11), home (12),
       assisted living facility (13), group home (14), mobile unit (15*),
       inpatient hospital (21), outpatient hospital (22), hospital emergency
       room (23), skilled nursing home for patients in a Part A stay (31),
       nursing facility for patients not in a Part A stay (32), custodial
       care facility (33), independent clinic (49), community mental health
       center (53) and state or local public health clinic (71).

       *Place of service 15 (mobile) should be used for mobile units
       performing diagnostic or therapeutic services. Mobile units going to
       other sites such as SNF, adult homes, physician offices etc., should
       be using the site of service of the place that they are going to be
       performing the service (e.g., 31, 32, 33, 11) and not mobile. However,
       if the mobile unit is not serving an entity which could be described
       by an existing place of service code, place of service 15 (Mobile
       Unit) should be used.

Coverage Topic
Diagnostic Tests and X-rays

CPT/HCPCS Codes

    76700           Ultrasound, abdominal, real-time with image
                    documentation; complete

    76705           Ultrasound, abdominal, real-time with image
                    documentation; limited (eg, single organ, quadrant,
                    follow up)

Other Comments
For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier should provide the patient with an acceptable advance notice of Medicare's possible denial of payment. An advance beneficiary notice (ABN) should be signed when a provider/supplier does not want to accept financial responsibility for the service.

Does this Article contain a "Least Costly Alternative" provision?
No

Revision History Explanation
Revision #4: Update made to Copyright information; Revised referring/ordering physician claim instructions.

Revision #3: Updated description of CPT codes. Expanded place of service.

Revision #2: No coverage changes made to this article as a result of LCD revision R096-3 (9). Effective date changed to coordinate with LCD #R96-3-9.

Revision #1: Minor changes. No coverage revisions.

This article was converted from an LMRP on 09/15/2004. Added places of service (14) and (24). Removed place of service (72) ­ not appropriate.