LCD TITLE: Pelvic Echography

Contractor's Determination Number 2005-10-01 LCD ID Number L19581
Primary Geographic Jurisdiction Idaho Secondary Geographic Jurisdiction: N/A
Oversight Region Region X CMS Consortium Western
Original Determination Effective Date 6/1/05 Original Determination Ending Date: N/A
Revision Effective Date For services performed on or after 10/1/05 Revision Ending Date: N/A

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2004 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 National Coverage Policy

  • Title XVIII of the Social Security Act, Section 1862 (a) (7). This section excludes routine physical check-ups.
  • Title XVIII of the Social Security Act, Section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be reasonable and medically necessary.
  • Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
  • CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Section 310 (http://www.cms.hhs.gov/manuals/), outlines coverage for qualified clinical trials.

Indications and Limitations of Coverage and/or Medical Necessity

Urinary tract imaging is not recommended in the routine evaluation of men with prostatism unless they have one or more of the following medically necessary indications: hematuria, urinary tract infection, renal insufficiency, history of urolithiasis, history of urinary tract surgery or surgery is planned.

A diagnosis of benign prostatic hypertrophy (BPH) does not indicate the medical necessity of an ultrasound for determination of bladder residual volume. The patient must have other factors which indicate the need for testing. A routine ultrasound for the purpose of determining residual volume is not a covered service when performed in the place of a routine catheterization. Routine catheterizations are not separately billable. This is included in the office visit. If the patient has medical indication for a complete study, CPT code 76856 should be reported. However the ICD-9 diagnosis code must indicate the medical necessity and the patients medical record must contain adequate documentation.

Medically necessary measurement of post-voiding residual urine and/or bladder capacity by ultrasound without imaging may be billed with CPT code 51798.

Coverage Topic: Diagnostic Tests and X-Rays

Coding Information

Bill Type Codes

999x    Not Applicable

Revenue Codes

99999    Not Applicable

CPT/HCPCS Codes

51798 Measurement Of Post-Voiding Residual Urine And/Or Bladder Capacity By Ultrasound, Non-Imaging
76830 Ultrasound, Transvaginal
76856 Ultrasound, Pelvic (Nonobstetric), B-Scan And/Or Real Time With Image Documentation; Complete
76857 Ultrasound, Pelvic (Nonobstetric), B-Scan And/Or Real Time With Image Documentation; Limited Or Follow-Up (Eg, For Follicles)

ICD-9 Codes that Support Medical Necessity

If a pelvic ultrasound is performed in relation to an illness, injury or specific symptomatology, the diagnosis code must reflect the medical necessity for the procedure.

179 Malignant neoplasm of uterus-part uns
180.0 Malignant neoplasm of endocervix
180.1 Malignant neoplasm of exocervix

THIS SECTION OF ICD-9 TABLE TRUNCATED FOR THE SAMPLE POLICY ON THE WEBSITE ONLY. THE ACTUAL POLICIES CONTAIN THE ENTIRE ICD-9 TABLE

598.2 Postoperative urethral stricture
600.11 Nodular prostate with urinary obstruction
625.0 Dyspareunia
789.34 Abdominal or pelvic swelling mass or lump left lower quadrant
V10.41 Personal history of malignant neoplasm of cervix uteri

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

Documentation Requirements

Medical documentation for all Medicare covered pelvic ultrasounds is expected to clearly and concisely indicate the medical necessity for the procedure within the patient's medical record, should chart review become necessary.

For the evaluation of men with prostatism with pelvic echography, entries in the medical record must reflect that the examination was not done for routine purposes and that one of the conditions outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" was present: hematuria, urinary tract infection, renal insufficiency, history of urolithiasis, history of urinary tract surgery or surgery is planned.

Appendices; N/A
Utilization Guidelines: N/A
Sources of Information and Basis for Decision

Medical texts, other Carrier policy, consultant

Advisory Committee Meeting Notes

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from various specialties within the medical community.

Start Date of Comment Period : 2/16/2005
End Date of Comment Period: 4/1/2005
Start Date of Notice Period: 4/2/2005
Revision History Number: 01
Revision History Explanation:

Revision number: 01
Revision effective date: 10/01/05
Revision explanation: 09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update. Code replaced: 599.6 Codes added: 599.60, 599.69

Last Reviewed On: N/A
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