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Local Coverage Determination (LCD) for Sinus X-ray(s) (L29046)
Contractor Information
Contractor Name First Coast Service Options, Inc.
Contractor Number
09101
Contractor Type
MAC - Part A
LCD Information
Document Information
LCD ID Number L29046
LCD Title Sinus X-ray(s)
Contractor's Determination Number A70210
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 06/30/2009
Revision Ending Date
CMS National Coverage Policy
CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 13, Sections 10, 20, 90 and 120.
CMS Change Request 4039, Transmittal 716, dated October 21, 2005.
CMS Change Request 3280, Transmittal 343, dated October, 29, 2004
Indications and Limitations of Coverage and/or Medical Necessity
Radiologic examination of the paranasal sinuses, for the purpose of this Local Coverage Determination (LCD), involves plain film(s) (X-Rays) of the paranasal sinuses. FCSO Medicare will consider these examinations medically reasonable and necessary to assess injury of the sinuses or to treat illness with related sinus pathology when the information is used for clinical decision making and is considered the standard of care.
In general, acute sinusitis does not require imaging. CT is considered the procedure of choice for the evaluation of patients with chronic sinusitis in those patients under consideration for surgery. The use of radiographs in the evaluation of sinusitis is not a covered service unless the medical record supports the need for additional diagnostic information beyond the current history and exam given failure of standard therapy. Also, the need for plain films over CT should be supported in the documentation.
Evaluation of sinus disease by plain film is of limited clinical benefit because plain films often underestimate the presence and degree of paranasal sinus disease. These tests are never covered for screening, i.e., in the absence of signs, symptoms, or disease.
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
071x Clinic - Rural Health
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
CPT/HCPCS Codes
70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN 3 VIEWS
70220 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF 3 VIEWS
ICD-9 Codes that Support Medical Necessity
012.80 OTHER SPECIFIED RESPIRATORY TUBERCULOSIS UNSPECIFIED EXAMINATION
473.0 - 473.9 opens in new window CHRONIC MAXILLARY SINUSITIS - UNSPECIFIED SINUSITIS (CHRONIC)
959.09 OTHER AND UNSPECIFIED INJURY TO FACE AND NECK
993.1 BAROTRAUMA SINUS
Diagnoses that Support Medical Necessity N/A
ICD-9 Codes that DO NOT Support Medical Necessity N/A
XX000 Not Applicable
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity N/A
General Information
Documentations Requirements
Medical record documentation maintained by the ordering/referring provider must indicate the medical necessity for performing the test, including:
• History and physical,
• Test results, including the X-ray report, and
• Office/progress note, including treatment of the patient’s condition based on X-ray results.
If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the test. The provider must state the clinical indication for the study in the order for the test.
In addition, documentation that the service was performed must be included in the patient’s medical record.
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.
Reimbursement of radiologic examination of the paranasal sinus (70210 and 70220) which exceeds the frequency or duration by the accepted standards of medical practice are not covered unless there are special circumstances which justify additional radiologic examination of the paranasal sinuses.
Sources of Information and Basis for Decision
America Academy of Otolaryngology-Head and Neck Surgery. (2007). Clinical practice guideline: Adult sinusitis. Retrieved from http://www.ent.org
American Academy of Otolaryngology-Head and Neck Surgery. (2009). Fact Sheet: Sinus Surgery. Retrieved from http://www.ent.net.org
American Family Physician. (2002). Radiologic Imaging in the Management of Sinusitis. Retrieved from http://www.aafp.org
National Guideline Clearinghouse. (2007). Acute Rhinosinusitis in adults. Retrieved from http://www.guidelines.gov
National Guideline Clearinghouse. (2008). Diagnosis and treatment of respiratory illness in children and adults.
Retrieved from
http://www.guidelines.gov 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 02/20/2009
End Date of Comment Period 04/06/2009
Start Date of Notice Period 05/01/2009
Revision History Number 1
Revision History Explanation Revision Number:1
Start Date of Comment Period:02/20/2009 Start Date of Notice Period:05/01/2009 Revised Effective Date: 06/30/2009
LCR A2009-055
April 2009 Bulletin
Explanation of Revision: This LCD is being revised to update verbiage in the following sections of the LCD: “Indications and Limitations of Coverage and/or Medical Necessity,” “Documentation Requirements,” “Utilization Guidelines,” “Sources of Information and Basis for Decision”. In the “ICD-9 Codes that Support Medical Necessity” section of the policy deleted ICD-9-CM code range for acute sinusitis (461.0-461.9) and diagnosis 471.1, and updated descriptors for all other codes. The “Type of Bill Code” and “Revenue Codes” sections were updated. The “LCD Title” was changed to ‘Sinus X-ray(s)’ and the Contractor’s Determination Number was changed to 70210. The effective date of this 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 A2009-034FL LCR A2009-036PR/VI
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) there was no previous LCD on this subject. This document (L29046) 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 71 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
Reason for Change
Related Documents
This LCD has no Related Documents.
LCD Attachments
Draft LCD Comment Summary
All Versions
Updated on 08/01/2010 with effective dates 06/30/2009 - N/A Updated on 08/01/2010 with effective dates 06/30/2009 - N/A Updated on 04/17/2009 with effective dates 06/30/2009 - N/A Updated on 04/17/2009 with effective dates 06/30/2009 - N/A Updated on 11/30/2008 with effective dates 02/16/2009 - N/A