L29414-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Sinus X-ray(s) (L29414)

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 L29414

LCD Title

Sinus X-ray(s)

Contractor's Determination Number 70210

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

For services performed on or after 06/30/2009

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 100-04, 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.

999x Not Applicable

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

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 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.

Florida Contractor Advisory Committee Meeting held on March 7, 2009.

Puerto Rico/U.S. Virgin Islands Contractor Advisory Meeting held on March 19, 2009

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:Original Start Date of Comment Period:02/20/2009

Start Date of Notice Period:05/01/2009 Original Effective Date: 06/30/2009

LCR B2009-067

April 2009 Update

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 “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:02/02/2009

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 there was no previous LCD on this subject. This document (L29414) is effective on 02/02/2009.

Reason for Change