LCD/NCD Portal

L29046 SINUS X-RAY(S)

 

 

06/30/2009

 

 

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.

o 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.

o 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.

o 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.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

71x Clinic - Rural Health

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

 

 

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 CHRONIC MAXILLARY SINUSITIS

473.1 CHRONIC FRONTAL SINUSITIS

473.2 CHRONIC ETHMOIDAL SINUSITIS

473.3 CHRONIC SPHENOIDAL SINUSITIS

473.8 OTHER CHRONIC SINUSITIS

473.9 UNSPECIFIED SINUSITIS (CHRONIC)

959.09 OTHER AND UNSPECIFIED INJURY TO FACE AND NECK

993.1 BAROTRAUMA SINUS

 

 

Documentation Requirements

 

• Medical record documentation maintained by the ordering/referring provider must indicate the medical necessity for performing the test, including:

o History and physical.

o Test results, including the X-ray report.

o 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.

o 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

 

• 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.

Treatment Logic

• Radiologic examination of the paranasal sinuses involves plain film(s) (X-Rays) of the paranasal sinuses.

• 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.

 

 

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

 

FCSO LCD 29414, Sinus X-ray(s), 06/30/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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

 

 

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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 

CMS LCD L29046 SINUS X-RAY(S)