L28808-LCD

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Automated World Health

Local Coverage Determination (LCD) for Computed Tomography Scans of the Head or Brain (L28808)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28808

LCD Title Computed Tomography Scans of the Head or Brain

Contractor's Determination Number A70450

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, Chapter 1, Section 220.1

Indications and Limitations of Coverage and/or Medical Necessity

Computed Tomography is the recording of internal body images at a pre-determined plane by x-ray. Computed tomography, or CAT scans, involve the measurement of the emergent x-ray beam by a scintillation counter. The electronic pulses are recorded on a magnetic disk and then processed by a minicomputer for reconstruction display of the body in cross-section on an electronic display.

Computed Tomography Scans Head or Brain:

Medicare will consider a computed tomography scan of the head or brain to be medically reasonable and necessary based on the American College of Radiology guidelines when performed to establish a diagnosis or to monitor treatment for the following conditions:

• Acute head trauma

• Suspected acute intracranial hemorrhage

• Detection or evaluation of calcification

• Immediate postoperative evaluation for surgical treatment of tumor or for surgical treatment of hemorrhage or hemorrhagic lesions

• Shunted hydrocephalus, or shunt revision

• Increased intracranial pressure

• Treated/untreated vascular lesions

• Acute neurologic deficits

• Suspected intracranial infection

• Suspected hydrocephalus

• Congenital lesions (such as, but not limited to, craniosynotosis, macrocephaly, and microcephaly)

• Evaluating psychiatric disorders

• Brain herniation

• Suspected mass or tumor

• Evaluation prior to MR to detect presence of metallic objects that would constitute a contraindication to MR evaluation. (This should be used to detect small metallic objects in an at-risk patient that would be too small or inadequate to detect with plain film evaluation.)

Coverage for headache should only be for the following situations:

• Patient suffering from headaches after a head injury.

• Patient suffering from headaches unusual in duration and not responding to medical therapy or those that are considered unusual in duration, character, severity or suddenness of onset.

Generally, a CT scan should only be considered for the evaluation of a headache after a history and physical exam has been performed.

When MR imaging is unavailable or contraindicated, or if the supervising physician deems CT to be appropriate, Medicare will consider CT to be medically necessary for the following secondary indications:

• Diplopia

• Cranial nerve dysfunction

• Seizures

• Apnea

• Syncope

• Ataxia (including dizziness and vertigo)

• Suspicion of neurodegenerative disease

• Developmental delay

• Neuroendocrine dysfunction

• Encephalitis

• Vascular occlusive disease or vasculitis (including use of CT angiography and/or venography

• Aneurysm

• Drug toxicity

• Cortical dysplasia

• Migration anomalies or other morphologic brain abnormalities

• Sinusitis

• Hearing loss and other otolaryngologic presentations, whose evaluation reaches the level of requiring such imaging

• Non-traumatic neurological central deficit with suspicion of infarction or bleeding

• Foreign body

• Thyroid ophthalmopathy/proptosis

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

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

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

70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL

70460 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S)

70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

ICD-9 Codes that Support Medical Necessity 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 the service is other than the ordering/referring physician, that provider must maintain 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 Emergency Physicians. (2002). Clinical policy Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache. Annals Emergency Medicine, 39:108-122.

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

American College of Radiology. (2009). Practice guideline for the performance of computed tomography (CT) of the brain. Retrieved August 9, 2010, from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/dx/head-neck/ct_brain.aspx

American College of Radiology. (2001). Practice guidelines for the performance of computed tomography (CT) of the extra-cranial head and neck in adults and children.

National Guideline Clearinghouse. (2005). Clinical policy: critical issues in the evaluation and management of patients presenting to the emergency department with acute headache.

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 Florida Diagnostic Radiology Society and the Florida Neurology Society.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2011

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:05/01/2011 Revision Effective Date :04/05/2011

LCR A2011-035

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 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 Revision Effective Date 08/17/2010

LCR A2010-047

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 (L28808) replaces LCD L1014 as the policy in notice. This document (L28808) 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 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

Reason for Change