LCD/NCD Portal

L32314

 

3D INTERPRETATION AND REPORTING OF IMAGING STUDIES

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications:

• 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.

o 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.

o The interpreting physician’s report should address the medical necessity identified by the ordering/referring physician/nonphysician practitioner.

o 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.

 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.

o 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.

o 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.

o 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.

 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 upon request.

o Three-dimensional imaging is medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient.

o 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.

o 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.

o 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.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

85x 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.

 

 

0320 Radiology - Diagnostic - General Classification

0321 Radiology - Diagnostic - Angiocardiology

0322 Radiology - Diagnostic - Arthrography

0323 Radiology - Diagnostic - Arteriography

0324 Radiology - Diagnostic - Chest X-Ray

0329 Radiology - Diagnostic - Other Radiology - Diagnostic

0350 CT Scan - General Classification

0351 CT Scan - CT - Head Scan

0352 CT Scan - CT - Body Scan

0359 CT Scan - CT Other

0400 Other Imaging Services - General Classification

0401 Other Imaging Services - Diagnostic Mammography

0402 Other Imaging Services - Ultrasound

0403 Other Imaging Services - Screening Mammography

0404 Other Imaging Services - Positron Emission Tomography

0409 Other Imaging Services - Other Imaging Services

0610 Magnetic Resonance Technology (MRT) - General Classification

0611 Magnetic Resonance Technology (MRT) - MRI - Brain/Brainstem

0612 Magnetic Resonance Technology (MRT) - MRI - Spinal Cord/Spine

0614 Magnetic Resonance Technology (MRT) - MRI - Other

0615 Magnetic Resonance Technology (MRT) - MRA - Head and Neck

0616 Magnetic Resonance Technology (MRT) - MRA - Lower Extremities

0618 Magnetic Resonance Technology (MRT) - MRA - Other

0619 Magnetic Resonance Technology (MRT) - Other MRT

0920 Other Diagnostic Services - General Classification

0921 Other Diagnostic Services - Peripheral Vascular Lab

0922 Other Diagnostic Services - Electromyelgram

0923 Other Diagnostic Services - Pap Smear

0924 Other Diagnostic Services - Allergy Test

0925 Other Diagnostic Services - Pregnancy Test

0929 Other Diagnostic Services - Other Diagnostic Service

 

 

CPT/HCPCS Codes

 

76376 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; 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 WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; 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 SOLITARY PULMONARY NODULE

793.19 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

 

 

Documentation 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 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.

o This documentation should be legible, must be maintained by the interpreting physician, and must be made available 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.

o Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.

 

Treatment Logic

• 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.

 

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.

 

FCSO LCD 32312, 3D Interpretation and Reporting of Imaging Studies, 01/01/2013. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

“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

 

 

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 L32314 3D INTERPRETATION AND REPORTING OF IMAGING STUDIES