L30353-LCD

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Local Coverage Determination (LCD) for Ultrasound of the Spine (L30353)

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 L30353

LCD Title

Ultrasound of the Spine

Contractor's Determination Number 76800

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 09/30/2009

Original Determination Ending Date

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (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 represent quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Part 4, Section 220.5 CMS Transmittal 76, Change Request 5608, dated 9/12/07

CMS Transmittal B-01-28, Change Request 850, dated 4/19/01

Indications and Limitations of Coverage and/or Medical Necessity

Ultrasound (US) imaging is a noninvasive diagnostic imaging modality that includes exposing part of the body to high-frequency ultrasound waves to produce both imaging and Doppler examinations. The images are captured in real-time and can illustrate the structure and movement of the internal organs of the body, and blood flowing through blood vessels.

Ultrasound of the spine is an accurate and cost-effective examination for the detection of congenital or acquired abnormalities in the newborn and infant. It may also be useful post-operatively for neonates and young infants in the evaluation of cord retethering and associated defects.

Indications

FCSO Medicare will consider ultrasound of the spine medically reasonable and necessary when used intra- operatively for adults; and for the newborn and infant in the diagnostic evaluation of the spinal cord and canal.

Limitations

FCSO Medicare considers non-operational adult ultrasound of the spine and paraspinal tissues for the evaluation of neuromuscular conditions and all other indications (for example, to assist in lumbar puncture or to assist with interventional pain injections) non-covered.

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

76800 ULTRASOUND, SPINAL CANAL AND CONTENTS

ICD-9 Codes that Support Medical Necessity N/A

XX000 Not Applicable

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 physician must indicate the medical necessity for the ultrasound of the spinal canal and contents covered by the Medicare program and made available to Medicare upon request. The procedure results/report must be included in the patient’s medical record.

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

Code of Federal Regulations (CFR), Title 42, part 410.32, specifies that all diagnostic tests must be ordered by a provider who is the treating provider for the patient and who will use the test results in the patient’s care (in regards to the treating provider, there may be exceptions for the diagnostic radiologist in certain institutional inpatient or outpatient patient settings).

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. It is expected that only one unit would be billed regardless of how many areas of the spine are visualized.

Some ultrasound machines have become increasingly compact and portable. Certain “hand-carried” scanners are “full featured” and permit a skilled examiner to image and record permanent records of all of the tomographic images and Doppler data (both color and spectral) needed to perform a complete diagnostic examination that may be quite comparable, in diagnostic value, to that obtained with a larger, “state of the art” instrument. In

order to qualify as a valid diagnostic ultrasound service, the study must be done for an accepted clinical indication by a properly trained examiner and must include a permanent record of the findings, data sufficient to support

the conclusions and an appropriate interpretation and written report. Such a study would meet the standards required for a complete diagnostic examination, regardless of the size of the instrument used to perform the study.

Some small scanners have limited capabilities and lack either the permanent recording capabilities or some of the functional capabilities needed to perform a complete examination. Such a study may be quite useful as an extension of the physical examination. However, an examination that does not meet the standards required for a complete diagnostic ultrasound examination – whether performed with a conventional scanner or a limited capability ultrasound scanner – will not be recognized as a valid diagnostic ultrasound service and will be non- covered.

Sources of Information and Basis for Decision

American Academy of Neurology. (2006). Review of the Literature on Spinal Ultrasound for the Evaluation of Back Pain and Radicular Disorders. Retrieved from http://www.aan.com/practice/guideline/index.cfm?fuseacton=home.date

American College of Radiology. (2007). ACR Practice guideline for the performance of an ultrasound examination of the neonatal spine. Retrieved from http://www.acr.org

American College of Radiology. (2006). ACR Practice guideline for performing and interpreting diagnostic ultrasound examinations. Retrieved from http://www.acr.org

American Institute of Ultrasound in Medicine. (2002). Nonoperative spinal/paraspinal ultrasound in adults. Retrieved from http://www.aium.org/publications/statements/

Radiological Society of North America, Inc. (2008) Radiology Info: What is General Ultrasound Imaging? Retrieved from http://www.radiologyinfo.org

Other Private Insurer’s practice guidelines.

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 June 20, 2009.

Puerto Rico and U.S. Virgin Islands Contractor Advisory Committee Meeting held on June 25, 2009.

Start Date of Comment Period 06/01/2009

End Date of Comment Period 07/15/2009

Start Date of Notice Period 08/15/2009

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:06/01/2009

Start Date of Notice Period:08/15/2009 Original Effective Date:09/30/2009

LCR B2009-085

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

76800 descriptor was changed in Group 1

Reason for Change