LCD/NCD Portal

L28806 COMPUTED TOMOGRAPHY OF THE ABDOMEN AND PELVIS

 

 

04/05/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

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

 

• Evaluation of pain.

o Abdomen

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

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

 Suspected diverticulitis or appendicitis.

o Pelvis

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

 Evaluation of pelvic fractures or bony tumors.

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

 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).

o Abdomen

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

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

 Persistent unresolved symptoms not explained by initial imaging.

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

o Pelvis

 Endometriosis follow-up of abnormal ultrasound.

 Inflammatory bowel disease, Crohns’s or colitis.

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

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

• Evaluation of known or suspected primary breast cancer metastasis.

• Evaluation of abdominal or pelvic trauma.

o Abdomen/Pelvis Combination

 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.

o Abdomen

 Delineation of known or suspected renal calculi.

 Pancreatitis, psyedocyst.

 Splenomegaly.

 Ascites.

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

 Hydronephrosis.

o Abdomen/Pelvis Combination

 Fever and elevated white count, suspected abscess.

 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.

o Pelvis

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

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

• Abdomen/Pelvis Combination

 Staging of known tumors or history of malignance.

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

 Lymphadenopathy, assessment of lymphomas.

 Presence or suspicion of abdominal mass/cancer.

• There are no absolute contraindications to abdominal CT or pelvic CT examinations.

o 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.

o 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.

o 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.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

85x 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.

 

0320 Radiology - Diagnostic - General Classification

0321 Radiology - Diagnostic - Angiocardiology

0322 Radiology - Diagnostic - Arthrography

0323 Radiology - Diagnostic - Arteriography

0324 Radiology - Diagnostic - Chest X-Ray

0329 Radiology - Diagnostic - Other Radiology - Diagnostic

0350 CT Scan - General Classification

0351 CT Scan - CT - Head Scan

0352 CT Scan - CT - Body Scan

0359 CT Scan - CT Other

 

 

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)

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

 

 

Documentation 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.

o 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.

o 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.

o 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.

o The physician must state the clinical indication/medical necessity for the study in his order for the test.

 

 

Rules for Testing Facility to Furnish Additional Tests:

 

• If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

o The testing center performs the diagnostic test ordered by the treating physician/practitioner.

o The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary.

o Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary.

o The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary.

o The interpreting physician at the testing facility documents in his/her report why additional testing was done.

 

 

Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests:

 

• The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient.

• The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.

 

 

Test Design:

 

• Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test. (e.g., number of radiographic views obtained, thickness or tomographic sections acquired, use or non-use of contrast media).

 

 

Utilization Guidelines

 

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

 

 

Treatment Logic:

 

• 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.

 

 

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

 

FCSO LCD, Computed Tomography of the Abdomen and Pelvis, 04/05/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th ed., Chapter 45. Copyright © 2001 Churchill Livingstone, Inc.

 

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]

 

Radiologic Clinics of North America; Volume 41, No. 6; November 2003. Copyright 2003 W.B. Saunders Company.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD COMPUTED TOMOGRAPHY OF THE ABDOMEN AND PELVIS