L28806-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Computed Tomography of the Abdomen and Pelvis (L28806)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28806

LCD Title

Computed Tomography of the Abdomen and Pelvis

Contractor's Determination Number A72192

Primary Geographic Jurisdiction

Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 04/05/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See § 1869 (f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual Chapter 1, Section 220.1

Change Request 7121, Transmittal 2037, dated August 27, 2010

Indications and Limitations of Coverage and/or Medical Necessity

CT of the abdomen includes the area between the dome of the diaphragm and the iliac crests, which also includes the base of the lungs. CT of the abdomen is generally indicated when only upper abdominal organs are of

interest. A typical CT of the abdomen should include transaxial images from the dome of the diaphragm to the

iliac crest with up to 10mm slice thickness. Pelvic CT includes the area between the iliac crests and the perineum. A typical CT of the pelvis would extend from the iliac crest to the ischial tuberosities with up to 10 mm slice thickness. If the patient has a suspected disease that may spread through the peritoneal cavity or by lymphatics, then the pelvic scan should also be performed. In some clinical situations, it may be medically necessary to perform complete CT scans of the abdomen and pelvis on the same date of service. These situations include but are not limited to the evaluation of inflammatory disease, staging of neoplasms and the evaluation of trauma.

Suggested indications for abdominal CT or pelvic CT examinations include, but are NOT LIMITED to the following:

• Evaluation of pain

Abdomen

a. Upper abdominal pain if ultrasound is normal (*Note: Ultrasound does not work well in obese patients)

b. Unexplained abdominal pain in patients older than 75 years or very frail

c. Suspected diverticulitis or appendicitis

Pelvis

a. Lower abdominal pain, if ultrasound is normal and clearly not a bowel problem

b. Evaluation of pelvic fractures or bony tumors

c. Bilateral hips for avascular necrosis as the femurs will be visualized on a pelvic study

d. Inguinal hernia suspect incarceration

• Evaluation of known or suspected abdominal or pelvic masses or fluid collections, primary or metastatic malignancies, abdominal or pelvic inflammatory processes, and abnormalities of

abdominal or pelvic vascular structures (Note – CT Scans utilized initially for suspected malignancies)

Abdomen

a. Jaundice or abnormal liver function tests if ultrasound is normal or not indicated

b. Possible renal tumor (often will have ultrasound first)

c. Persistent unresolved symptoms not explained by initial imaging

d. Follow-up metastasis (i.e., breast, lung cancer, etc.)

Pelvis

a. Endometriosis follow-up of abnormal ultrasound

b. Inflammatory bowel disease, Crohns’s or colitis

c. Evaluation of bladder, cervical, ovarian, prostate or rectal cancer

d. Follow-up metastasis (i.e., breast, lung cancer, etc.)

• Evaluation of known or suspected primary breast cancer metastasis

• Evaluation of abdominal or pelvic trauma

Abdomen/Pelvis Combination

a. Blunt trauma – splenic laceration , trauma to the kidneys, suspicion of intra-abdominal fluid collections related to trauma

• Clarification of findings from other imaging studies or laboratory abnormalities

Abdomen

a. Delineation of known or suspected renal calculi

b. Pancreatitis, psyedocyst

c. Splenomegaly

d. Ascites

e. Hematuria or blood in urine (consider obtaining both abdomen and pelvis)

f. Hydronephrosis

Abdomen/Pelvis Combination

a. Fever and elevated white count, suspected abscess

b. Infection, unexpected weight loss

• Evaluation of known or suspected congenital abnormalities of abdominal or pelvic organs

• Guidance for interventional, diagnostic, or therapeutic procedures within the abdomen or pelvis

• Treatment planning for radiation therapy

Pelvis

a. Prostate tumor – staging for regional adenopathy, as part of radiation treatment planning

b. Follow-up of known mass, abscess or tumor

Abdomen/Pelvis Combination

a. Staging of known tumors or history of malignance

b. Assessment of response to chemotherapy and radiation therapy in individuals undergoing treatment

c. Lymphadenopathy, assessment of lymphomas

d. Presence or suspicion of abdominal mass/cancer

There are no absolute contraindications to abdominal CT or pelvic CT examinations. As with all procedures, the relative benefits and risks of the procedure should be evaluated prior to the performance of iodinated contrast- enhanced abdominal CT and pelvic CT. Appropriate precautions should be taken to minimize patient risk.

CT scans performed by mobile CT scan services are eligible for reimbursement only as specified in the Medicare National Coverage Determinations Manual Chapter 1-220.1.

CT scans performed on mobile units are subject to the same Medicare coverage requirements applicable to scans performed on stationary units, as well as certain health and safety requirements recommended by Health Resources and Services Administration (HRSA). As with scans performed on stationary units, the scans must be determined medically necessary for the individual patient. The scans must be performed on types of CT scanning equipment that have been approved for use as stationary units and must be in compliance with applicable State laws and regulations for control of radiation.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

032X Radiology - Diagnostic - General Classification 035X CT Scan - General Classification

CPT/HCPCS Codes

72192 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL

72193 COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S)

72194 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

74150 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL

74160 COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S)

74170 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

74176 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL

74177 COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL(S)

COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH 74178 BODY REGIONS, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH

BODY REGIONS

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, and interpretive report and copies of all images obtained. The computerized data with image reconstruction should also be maintained.

The medical record must contain documentation, including a written or electronic request for the procedure which fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited

to relevant medical history, physical examination, diagnosis (if known), pertinent signs and symptoms and results of pertinent diagnostic tests and/or procedures. This entire documentation-not just the test report or the findings/diagnosis on the order, must be made available to Medicare upon request.

When a CT scan and MRI are performed on the same day for the same anatomical area, the medical record must clearly reflect the medical necessity for performing both tests

If the provider of service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American College of Radiology (2010). Practice guideline for communication of diagnostic imaging findings. Retrieved from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines.aspx

ACR Practice Guideline For The Performance Of Computed Tomography (CT) Of The Abdomen And Computed Tomography (CT) Of The Pelvis Revised 2006] [On-Line]. Available: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/gastro/ct_abdomen_pelvis.aspx

ACR Practice Guideline For Performing And Interpreting Diagnostic Computed Tomography (CT). Revised 2006 [On-Line]. Available: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/ct_performing_interpreting.aspx

Harisinghani, MG - Gastroenterol Clin North Am - 01-SEP-2002; 31(3): 759-76, vi. NIH/NLM MEDLINE.

Lee, S., Coughlin, B., Wolfe, J., Polino, J., Blank, F., & Smithline, H. (2006), Prospective comparison of helical CT of the abdomen and pelvis without and with oral contrasts in assessing acute abdominal pain in adult Emergency Department patients. Emergency Radiology, 12: 150-157.

NIA Diagnostic Imaging Guidelines. [On-Line]. Available: . [2005, March]

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 3

Revision History Explanation Revision Number: 3 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2011

Revised Effective Date: 04/05/2011

LCR A2011-040

April 2011 Bulletin

Explanation of Revision: Under the “Documentation Requirements” section of the LCD, verbiage was updated to be in line with the guidelines used to develop the LCD. In addition, references were updated under the “Sources of Information and Basis for Decision” section of the LCD. The effective date of this LCD revision is based on date of service

Revision Number2

Start Date of Comment Period:N/A Start Date of Notice Period:01/01/2011 Revised Effective Date 01/01/2011

LCR A2011-006

December 2010 Bulletin

Explanation of Revision: Annual 2011 HCPCS Update. Added new CPT codes 74176, 74177, and 74178 and descriptors to “CPT/HCPCS Codes” section. The effective date of this revision is based on date of service.

Revision Number 1

Start Date of Comment Period:N/A Start Date of Notice Period:09/01/2010 Revised Effective Date 08/17/2010

LCR A2010-048

August 2010 Bulletin

Explanation of Revision: Under the “Documentation Requirements” section of the LCD, verbiage pertaining to ordering contrast was deleted for consistency with other LCDs of similar testing. In addition, references were updated under the “Sources of Information and Basis for Decision” section of the LCD. The effective date of this LCD revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28806) replaces LCD L995 as the policy in notice. This document (L28806) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0320 was changed 8/1/2010 - The description for Revenue code 0321 was changed 8/1/2010 - The description for Revenue code 0322 was changed 8/1/2010 - The description for Revenue code 0323 was changed 8/1/2010 - The description for Revenue code 0324 was changed 8/1/2010 - The description for Revenue code 0329 was changed 8/1/2010 - The description for Revenue code 0350 was changed 8/1/2010 - The description for Revenue code 0351 was changed 8/1/2010 - The description for Revenue code 0352 was changed 8/1/2010 - The description for Revenue code 0359 was changed

11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

74176 descriptor was changed in Group 1 74177 descriptor was changed in Group 1 74178 descriptor was changed in Group 1

Reason for Change