LCD/NCD Portal

L30353

 

ULTRASOUND OF THE SPINE

 

09/30/2009

 

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.

o 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.

o 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.

 

CPT/HCPCS Codes

 

76800 ULTRASOUND, SPINAL CANAL AND CONTENTS

 

Documentation 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.

o 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).

 

Utilization Guidelines

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

o 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.

o 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.

o 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.

o 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.

o Such a study may be quite useful as an extension of the physical examination.

o 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.

 

09/30/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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 ULTRASOUND OF THE SPINE