L29300-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Ultrasound, Soft Tissues of Head and Neck (L29300)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29300

LCD Title

Ultrasound, Soft Tissues of Head and Neck

Contractor's Determination Number 76536

Primary Geographic Jurisdiction opens in new window

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 02/02/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 14, Section 10

Indications and Limitations of Coverage and/or Medical Necessity

Medicare will consider ultrasound of the head and neck medically reasonable and necessary when used for the following indications:

• Evaluation of abnormalities in the tissues and/or organs of the head and neck (i.e., palpable masses)

• Evaluation of abnormalities detected on other imaging examinations (i.e., areas of abnormal uptake seen on radioisotope thyroid examinations)

• Personal or family history of thyroid malignancies

•Evaluation of suspected regional nodal metastases in patients with a proven thyroid carcinoma

• Follow-up of lesion/nodule (i.e., after medical suppression therapy)

• Localization of thyroid/parathyroid glands or cervical lymph nodes for biopsy, ablation, or other interventional procedures

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.

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.

99999 Not Applicable

CPT/HCPCS Codes

76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION

ICD-9 Codes that Support Medical Necessity

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

193 MALIGNANT NEOPLASM OF THYROID GLAND

194.1 MALIGNANT NEOPLASM OF ADRENAL GLAND

194.2 MALIGNANT NEOPLASM OF PARATHYROID GLAND

194.5 MALIGNANT NEOPLASM OF CAROTID BODY

195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK

196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK

200.01 RETICULOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.11 LYMPHOSARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

200.31 MARGINAL ZONE LYMPHOMA,LYMPH NODES OF HEAD, FACE, AND NECK

200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.51 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.61 ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

200.71 LARGE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

215.0 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

226 BENIGN NEOPLASM OF THYROID GLANDS

227.1 BENIGN NEOPLASM OF PARATHYROID GLAND

234.8 CARCINOMA IN SITU OF OTHER SPECIFIED SITES

239.7

240.0 - 240.9 NEOPLASM OF UNSPECIFIED NATURE OF ENDOCRINE GLANDS AND OTHER PARTS OF NERVOUS SYSTEM GOITER SPECIFIED AS SIMPLE - GOITER UNSPECIFIED

241.0 - 241.9 NONTOXIC UNINODULAR GOITER - UNSPECIFIED NONTOXIC NODULAR GOITER

242.00 - 242.91TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM -THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR

STORM

245.1 ACUTE THYROIDITIS

245.2 SUBACUTE THYROIDITIS

245.9 THYROIDITIS UNSPECIFIED

246.0 - 246.9 opens in new window

DISORDERS OF THYROCALCITONIN SECRETION - UNSPECIFIED DISORDER OF THYROID

252.8 OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND

682.1 CELLULITIS AND ABSCESS OF FACE

682.2 CELLULITIS AND ABSCESS OF NECK

759.2 ANOMALIES OF OTHER ENDOCRINE GLANDS CONGENITAL

784.2 SWELLING MASS OR LUMP IN HEAD AND NECK

785.6 ENLARGEMENT OF LYMPH NODES

794.5 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF THYROID

V10.87 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF THYROID

V15.3 PERSONAL HISTORY OF IRRADIATION PRESENTING HAZARDS TO HEALTH

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity 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 physician must indicate the medical necessity for the ultrasound of the head and neck covered by the Medicare program. The procedure results/report must be included in the patient’s medical record.

If the provider of the ultrasound of the head and neck is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of the procedure results/report along with copies of the ordering/referring physician’s order for the procedure.

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

Mosby’s Diagnostic and Laboratory Test Reference - 2nd Edition. Source used to define the procedure.

Taber’s Cyclopedic Medical Dictionary. Source used to define diagnoses.

Marqusee, E., Benson, C., et al (2000). How useful is ultrasonography in the management of thyroid nodules. Annuals of Internal Medicine; 133: 696-700. Source used to define indications for thyroid ultrasound.

Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

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

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29300) replaces LCD L13868 as the policy in notice. This document (L29300) is effective on 02/02/2009.

Reason for Change