LCD/NCD Portal

L29121 COMPUTED TOMOGRAPHY SCANS OF THE HEAD OR BRAIN

 

 

04/05/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Computed Tomography Scans head of 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:

o Acute head trauma.

o Suspected acute intracranial hemorrhage.

o Detection or evaluation of calcification.

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

o Shunted hydrocephalus, or shunt revision.

o Mental status change.

o Increased intracranial pressure.

o Treated/untreated vascular lesions.

o Acute neurologic deficits.

o Suspected intracranial infection.

o Suspected hydrocephalus.

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

o Evaluating psychiatric disorders.

o Brain herniation.

o Suspected mass or tumor.

o 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:

o Patient suffering from headaches after a head injury.

o 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:

o Diplopia.

o Cranial nerve dysfunction.

o Seizures.

o Apnea.

o Syncope.

o Ataxia (including dizziness and vertigo).

o Suspicion of neurodegenerative disease.

o Developmental delay.

o Neuroendocrine dysfunction.

o Encephalitis.

o Vascular occlusive disease or vasculitis (including use of CT angiography and/or venography).

o Aneurysm.

o Drug toxicity.

o Cortical dysplasia.

o Migration anomalies or other morphologic brain abnormalities.

o Sinusitis.

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

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

o Foreign body.

o Thyroid ophthalmopathy/proptosis.

 

 

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

 

 

Documentation Requirements

 

• The documentation of the study requires

o A formal written report, with clear identifying demographics.

o The name of the interpreting provider.

o Reason for the test.

o 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.

 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 the 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 clearly state the clinical indication/medical necessity for the study in the 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.

o 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).

 

 

Treatment Logic

 

• Computed Tomography is the recording of internal body images at a pre-determined plane by x-ray. Computed tomography, or CT 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.

 

 

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. Retrieved 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.

 

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

 

FCSO LCD 29121, Computed Tomography Scans of the Head or Brain, 04/05/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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

04/05/2011

 

 

AMA CPT / ADA CDT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2012 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 COMPUTED TOMOGRAPHY SCANS OF THE HEAD OR BRAIN