Contractor Name
HealthNow UMD

Contract Number
00801

Contractor Type
Carrier

LCD Database ID Number
L3573

LCD Title
Abdominal Retroperitoneal Ultrasound

Contractor's Determination Number
R-97-1 (6A) End dated

AMA CPT Copyright Statement
CPT codes, descriptions, and other data only are copyright 2007 American Medical Association (or such other data 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. (C) 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)(7)

       This section excludes routine physical examinations.

   -   Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)

       This section allows coverage and payment for only those services
       considered medically reasonable and necessary.

   -   Title XVIII of the Social Security Act, Section 1833 (e)

       This section prohibits Medicare payment for any claim which lacks the
       necessary information to process the claim.

   -   CMS Manual System, Pub100-4, Medicare Claims Processing Manual,
       Chapter 13, Section 20 and 90.

       These sections address payment for radiology services and for portable
       x-ray services.

Oversight Region
Region II

CMS Consortium
Northeast

Original Determination Effective Date
For services performed on or after 12/01/1997

Original Determination Ending Date
05/15/2008

Revision Effective Date
For services performed on or after 10/01/2007

Revision Ending Date
05/15/2008

Indications and Limitations of Coverage and/or Medical Necessity
Retroperitoneal ultrasound studies represent the ultrasonic imaging of retroperitoneal organs. The state of the art of ultrasound demands a high degree of manual dexterity, hand-eye coordination, a thorough understanding of anatomy, physiology, pathology, patient contours capabilities and limitations, and transducer characteristics.

A complete study visualizes all the structures or organs within the anatomic description of that study. A limited study involves a single quadrant or a single diagnostic problem, or an evaluation of an organ of interest. Limited studies may be used to re-evaluate a problem after the initial study in order to clarify a finding on the initial study.

   1.  Abdominal aorta and renal arteries--Aneurysms of abdominal aorta are
       usually diagnosed by physical exam or coincidentally by other x-ray
       studies.  Ultrasound is very accurate for aortic measurement and may
       be used to follow patients with aneurysms.

   2.  Inferior Vena Cava--Ultrasound is useful in detection of invasion by
       adjacent tumors and identification of obstruction levels.  It is also
       of value in the follow up of vena cava filter localization.   It may
       be of some use to identify the level of proliferative clot above the
       inguinal ligament.

   3.  Kidneys, ureter, and bladder:

       a.   Kidneys:

            The medical necessity of IVP and ultrasound have broad
            overlapping indications and should be utilized judiciously at the
            same encounter only if proper diagnostic dilemma exists.

            Ultrasound is useful to preclude obstruction in symptomatic
            patients and for guidance of percutaneous nephrostomy tubes.  It
            also may confirm scarred or small kidneys in chronic renal
            cortical disease, but is of no use in detecting early or mild
            cortical disorders or to categorize specific types of cortical
            diseases.

            Ultrasound is useful in detecting and following of renal cysts
            and localizing solid masses.  Benign renal cysts should be
            followed if they become symptomatic.  Otherwise, they should be
            considered relatively harmless.

       b.   Ureter:

            Ureters are usually not well visualized by ultrasound, especially
            in their mid portions; but ultrasound may rarely be helpful to
            confirm the presence of dilatation, filling defects, or a mass in
            its most proximal or distal portions.  Ultrasound also has a role
            in vesicle ureteral reflex.

       c.   Bladder:

            Tumors of the bladder are most efficiently followed by cystoscopy
            and urography.  However, ultrasound is useful in following
            intraluminal bladder tumor with or without extraluminal
            extension; including evaluation of bladder wall thickness and
            irregularity.

   4.  Renal Transplants:

       Ultrasound is indicated to detect urinary obstruction, fluid
       collections, vascular complications of renal transplants and is
       considered a primary tool in this endeavor.  Utilization frequency of
       this modality for renal transplants is dictated by the presence and
       absence of signs and symptoms.

   5.  Adenopathy--CT is far more accurate than ultrasound in detecting and
       delineating adenopathy.  Therefore, ultrasound should be of secondary
       importance and rarely utilized in the detection or follow up of nodal
       disease.

   6.  Prostate:

       Evaluation of the prostate is primarily done transrectally, by
       ultrasound

   7.  Adrenal Gland:

       Ultrasound is of little value since CT is considered more accurate.

   8.  Connective Tissue Tumors:

       These are usually detected by physical exam or CT.  Ultrasound is of
       limited value.

CPT/HCPCS Codes

    76770           Ultrasound, retroperitoneal (e.g., renal, aorta,
                    nodes), real time with image documentation; complete

    76775           ; limited

Does the CPT 30% Coding Rule Apply?
No

ICD-9-CM Codes That Support Medical Necessity
TRUNCATED DIAGNOSIS CODES ARE NOT ACCEPTABLE.

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.

Further, these ICD-9-CM codes can be used only with the conditions listed in the "Indications" and "Limitations" section of this determination.

    158.0-158.9     Malignant neoplasm of retroperitoneum - Malignant
                    neoplasm of peritoneum unspecified

    189.0-189.9     Malignant neoplasm of kidney except pelvis -
                    Malignant neoplasm of urinary organ site unspecified

    197.6           Secondary malignant neoplasm of retroperitoneum and
                    peritoneum

    200.00-200.88   Reticulosarcoma unspecified site - other naked
                    variants of lymphosarcoma and reticulosarcoma
                    involving lymph nodes of multiple sites

    201.00-201.98   Hodgkin's paragranuloma unspecified site - Hodgkin's
                    disease unspecified type involving lymph nodes of
                    multiple sites

    202.00-202.98   Nodular lymphoma unspecified site - other and
                    unspecified malignant neoplasms of lymphoid and
                    histiocytic tissue involving lymph nodes of multiple
                    sites.

    223.0-223.9     Benign neoplasm of kidney except pelvis - benign
                    neoplasm of urinary organ site unspecified

    403.00-403.91   Hypertensive chronic kidney disease,malignant, with
                    chronic kidney disease Stage I through Stage IV, or
                    unspecified-hypertensive chronic kidney disease,
                    unspecified, with chronic kidney disease Stage V or
                    end stage renal disease

    441.02          Aortic aneurysm and dissection/abdominal

    441.03          Aortic aneurysm and dissection/thoracoabdominal

    441.3           Abdominal aneurysm, ruptured

    441.4           Abdominal aneurysm without mention of rupture

    441.5           Aortic aneurysm of unspecified site, ruptured

    442.1           Other aneurysm of renal artery

    453.3           Other venous embolism and thrombosis of renal vein

    459.2           Compression of vein

    580.0-580.9     Acute glomerulonephritis with lesion of
                    proliferative glomeruloneuritis - acute
                    glomerulonephritis with unspecified pathological
                    lesion in kidney

    581.0-581.9     Nephrotic syndrome with lesion of proliferative
                    glomerulonephritis-nephrotic syndrome with
                    unspecified pathological lesion in kidney

    582.0-582.9     Chronic glomerulonephritis with lesion of
                    proliferative glomerulonephritis - chronic
                    glomerulonephritis with unspecified pathological
                    lesion in kidney

    583.0-583.9     Nephritis and nephropathy not specified as acute or
                    chronic with lesion of proliferative
                    glomeruloneuritis- nephritis and nephropathy not
                    specifed as acute or chronic with unspecified
                    pathological lesion in kidney

    584.5-584.9     Acute renal failure with lesion of tubular necrosis
                    -acute renal failure unspecified

    585.1           Chronic kidney disease, Stage I

    585.2           Chronic kidney disease, Stage II (mild)

    585.3           Chronic kidney disease, Stage III (moderate)

    585.4           Chronic kidney disease, Stage IV (severe)

    585.5           Chronic kidney disease, Stage V

    585.6           End stage renal disease

    585.9           Chronic kidney dissease, unspecified

    586             Renal failure, unspecified

    587             Renal sclerosis, unspecified

    589.0-589.9     Unilateral small kidney-small kidney unspecified

    590.00-590.9    Chronic pyelonephritis without lesion of renal
                    medullary necrosis-infection of kidney unspecified

    591             Hydronephrosis

    592.0           Calculus of kidney

    593.1           Hypertrophy of kidney

    593.2           Cyst of kidney, acquired

    593.9           Unspecified disorder of kidney and ureter

    599.0           Urinary tract infection, site not specified

    599.60          Urinary obstruction, unspecified

    599.69          Urinary obstruction, not elsewhere classified

    599.7           Hematuria

    785.9           Other symptoms involving cardiovascular system

    788.5           Oliguria and anuria

    789.30-789.39   Abdominal or pelvic swelling mass or lump
                    unspecified site-abdominal or pelvic swelling mass
                    or lump other specified site

    794.4           Nonspecific abnormal results of function
                    studies/kidney

    996.1           Mechanical complication of other vascular device,
                    implant, and graft

    996.81          Complications of transplanted kidney

    V71.1           Observation for suspected malignant neoplasm

ICD-9-CM Codes That DO NOT Support Medical Necessity:
Use of any ICD-9-CM code not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy will be denied

Documentation Requirements

   1.  Each claim must be submitted with ICD-9-CM codes that reflect the
       condition of the patient, and indicate the reason(s) for which the
       service was performed.  Claims submitted without ICD-9-CM codes will
       be returned.

   2.  All studies must have an interpretation on file and should be
       available for review.  The report should give the indication for the
       study.

   3.  Hard copy and/or video images should also be on file and be available
       for review.

   4.  For studies done at the request of a referring physician, the
       requisition should be kept on file as well.

   5.  For studies done where the referring physician is also the physician
       completing the study, the office records should reflect a clear need
       for these studies.

   6.  Documentation must be available to Medicare upon request.

Advisory Committee Meeting Notes

   -   This policy is being adopted from Empire Medicare Services' policy
       that was presented to the CAC on June 11, 1997.  Changes to this
       policy that was originally presented to the CAC on June 11, 1997, by
       Empire Medicare Services are the direct results from comments that
       were received from James Chang, M.D., alternate representative for the
       New York State Radiological Society.

   -   This policy does not reflect the sole opinion of the contractor or
       Contractor Medical Director.  Although the final decision rests with
       the carrier, this policy was developed in cooperation with advisory
       groups, which includes representatives from the New York State
       Radiological Society, Inc. and the Medical Society of the State of New
       York.

End Date of Comment Period
07/27/1997

Start Date of Notice Period
01/31/2008

Revision History Number
5

Revision History Explanation
This LCD is end dated because it is no longer an effective education tool.

Revision #5: Update of ICD-9CM descriptions completed for 2007.

Revision #4: Removed truncated ICD-9CM codes 585 and 599.6. Revised the description of code 76770 effective January 1, 2007.

Revision #3: This LCD is revised to include 785.9 as payable. No changes made to Coding Guidelines article

Revision #2: Updated policy to new format, revised description for code 76770/76775 and added Benefit Category and Coverage Topics.

Revision #1: Deleted item 3a, paragraph 4 from Indications & Limitations. Added 599.7, Hematuria, to the covered list of ICD-9CM codes.

This LCD was converted from an LMRP on 9/24/2004