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Local Coverage Determination (LCD) for 3D Interpretation and Reporting of Imaging Studies (L32314)

 

 

Contractor Information

 

Contractor Name

First Coast Service Options, Inc. opens in new window

 

Contractor Number 09101

 

Contractor Type MAC - Part A

 

LCD Information

Document Information

 

LCD ID Number L32314

 

LCD Title

3D Interpretation and Reporting of Imaging Studies

 

 

Contractor's Determination Number A76376

 

 

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.

 

Primary Geographic Jurisdiction opens in new window Florida

 

Oversight Region Region IV

 

Original Determination Effective Date

For services performed on or after 01/31/2012

 

Original Determination Ending Date

 

Revision Effective Date

For services performed on or after 01/31/2012

 

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. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 80 and 80.6 – 80.6.4 CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1 42 CFR §410.32

42 CFR §482.26

 

Indications and Limitations of Coverage and/or Medical Necessity

Indications:

 

The technological approach of multi-slice imaging along with the enhanced imaging techniques has allowed for the generation of three-dimensional (3D) images known as 3D reconstruction or 3D rendering. Three-dimensional imaging has been applied to ultrasound, echocardiography, computed tomography (CT), magnetic resonance imaging (MRI), and other tomographic modalities. Applications of this technology include, for example, coronary artery imaging, visualization of central nervous system vasculature, and enhanced imaging of the thorax which includes, for example, aortic aneurysms, embolic disease, and inflammatory and neoplastic lesions. As with any diagnostic testing, the procedure should be furnished in  accordance with accepted standards of medical practice based on the patient’s diagnosis, signs, and symptoms. This additional procedure applied to

a base procedure must meet but not exceed the patient’s medical need.

 

Three dimensional rendering codes should be reserved for situations where the additional image is necessary for a complete depiction of an abnormality from the 2D study or for surgical planning.

 

For non-hospital based outpatient services, it is expected that the ordering/referring physician/nonphysician practitioner generate a written order/referral indicating the medical necessity for the additional 3D imaging. In addition, it is expected that the interpreting physician maintain a copy of the test results and interpretation along with a copy of the ordering/referring physician/nonphysician practitioner’s order for the study. The interpreting physician’s report should address the medical necessity identified by the ordering/referring physician/nonphysician practitioner. In the event it is deemed by the interpreting physician that a 3D interpretation is urgently needed and the ordering/referring physician/nonphysician practitioner is not immediately available, the interpreting physician must document the following on the radiology report: the time of the study; specific medical need for the study; and a legible summary of the findings that were urgently transmitted to the ordering/referring physician/nonphysician practitioner whose name is on the order for the study.

 

For hospital based services (inpatient/outpatient), it is expected that there should be an order for the 3D image. In the absence of the order for the 3D image, if the hospital’s interpreting physician deems that the 3D interpretation is needed, he or she should clearly state in the interpretation the medical necessity for this separate service, in addition to the base procedure.

 

Limitations:

 

CPT codes 76376 and 76377 will not be considered medically reasonable and necessary if equivalent information obtained from the test has already been provided by another procedure (ultrasound, MRI, angiography, etc.) or if it could be provided by a standard CT scan (two-dimensional) without reconstruction.

 

3D rendering with interpretation and reporting during a radiation oncology episode of care is included in 3D simulation when applicable or IMRT plan when applicable and, therefore, should not be billed.

 

Notice: This local coverage determination (LCD) imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in the Centers for Medicare & Medicaid Services (CMS) payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

 

As published in the CMS online manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1: In order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

 

• Safe and effective;

 

• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary); and

 

• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

 

• Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;

 

• Furnished in a setting appropriate to the patient's medical needs and condition;

 

• Ordered and furnished by qualified personnel;

 

• One that meets, but does not exceed, the patient's medical need; and

 

• At least as beneficial as an existing and available medically appropriate alternative.

 

 

The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be made available to Medicare upon request. Three-dimensional imaging is medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. Providers billing Medicare are encouraged to obtain additional information from referring providers and/or patients or medical records to determine the medical necessity of studies performed. Referring physicians are required to provide appropriate diagnostic information to the performing provider.

 

Three-dimensional imaging will not be covered when performed based on internal protocols of the testing facility; a referral for one 3D imaging is not a blanket referral for all studies. In most cases, it is expected that the provider treating the patient specifically orders the procedure in writing and that the order should be on record for each 3D imaging performed.

 

 

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.

 

 

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

085x Critical Access Hospital

 

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.

 

 

032X Radiology - Diagnostic - General Classification 035X CT Scan - General Classification

040X Other Imaging Services - General Classification

061X Magnetic Resonance Technology (MRT) - General Classification 092X Other Diagnostic Services - General Classification

 

CPT/HCPCS Codes

76376 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

76377 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION

 

ICD-9 Codes that Support Medical Necessity

Covered Secondary Diagnoses:

 

The following list of diagnoses have been established as limited coverage for CPT codes 76376 and 76377 and must be accompanied by a primary diagnosis code on the claim indicating medical necessity for the study:

 

793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD

793.11 - 793.19 opens in new

window SOLITARY PULMONARY NODULE - OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD

793.2 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS

793.4

 

NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT

793.5 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GENITOURINARY ORGANS

793.6 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM

793.7 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM

 

 

Diagnoses that Support Medical Necessity

 

ICD-9 Codes that DO NOT Support Medical Necessity

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

 

Diagnoses that DO NOT Support Medical Necessity

 

 

General Information

Documentations Requirements

 

The following documentation must be included in the patient’s medical record:

 

• For non-hospital based outpatient services, the medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must clearly indicate the medical necessity of the 3D imaging and includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

 

• Documentation should clearly support one of the covered secondary diagnosis code(s) for medical necessity of 3D rendering and interpretation.

 

• The documentation should state the need for this separate service and should be included in the interpretation. The documentation should be legible, must be maintained in the patient’s medical record, and must be made available to Medicare upon request.

 

• When 3D interpretation is deemed urgently needed by the interpreting physician, the documentation must include the time of the study, the specific medical need for the study, and a summary of the findings that were urgently needed and transmitted to the ordering/referring physician /nonphysician practitioner whose name is on the order/referral for the study. This documentation should be legible, must be maintained by the interpreting physician, and must be made available to Medicare upon request.

 

Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are

not reasonable and necessary.

 

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.

 

Sources of Information and Basis for Decision

American College of Radiology. (2011). Coding Q & A. Retrieved from http://www.acr.org/Hidden/Economics/FeaturedCategories/Pubs/coding_source/archives/NovemberDecember2005/Coding_qa.aspx.

 

American College of Radiology. (2006). 2006 CPT® Code Update. Retrieved from http://www.acr.org/hidden/economics/featuredcategories/pubs/coding_source/archives/septemberoctober2005/2006cptcodeupdatedoc1.aspx.

 

“3D Interpretation and Reporting of Imaging Studies,” Palmetto GBA LCD, (01102) L28229. “3D Interpretation and Reporting of Imaging Studies,” TrailBlazer LCD, (04302) L26740.

“3D Interpretation and Reporting of Imaging Studies,” Wisconsin Physicians Services Insurance Corporation LCD, (05302) L30729

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.

 

Start Date of Comment Period 10/07/2011

 

End Date of Comment Period 11/21/2011

 

Start Date of Notice Period 12/16/2011

 

Revision History Number original

 

Revision History Explanation Revision Number:original Start Date of Comment Period:10/07/2011

Start Date of Notice Period:12/16/2011

Original Effective Date:01/31/2012

 

LCR A2011-092

December 2011 Connection

 

Reason for Change

 

Related Documents

This LCD has no Related Documents.

 

LCD Attachments

Comment Summary 10/7/11-11/21/11 opens in new window (a comment and response document)

 

 

All Versions

Updated on 12/10/2011 with effective dates 01/31/2012 - N/A Updated on 12/08/2011 with effective dates 01/31/2012 - N/A Read the LCD

 

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