SUBJECT: ULTRASOUND, ABDOMINAL

POLICY NUMBER:

The following policy reflects changes in the Carrier's existing policy which was previously published in our March 1, 1996 Medicare Providers' News (LA96-02). In accordance with the new 1998 ICD-9 updates, the Carrier will allow ICD-9 code 756.71 for prune belly syndrome. Also under VI. Vascular Structures, the verbiage "or an abdominal bruit is appreciated" has been removed. The rest of the policy remains unchanged.

DESCRIPTION:

The following guidelines do not represent a complete list of indications for the utilization of ultrasound, but do represent an attempt to aide an informed imaging selection based upon current literature and equipment. Utilization of this procedure for diagnostic purposes that clearly fall outside of these guidelines must be documented in your records for review. It is quite obvious that despite equipment improvements, ultrasound imaging limitations remain - most important of which is the high level of operator dependence. Consistent and accurate results can only be expected if the examiner and the interpreter have adequate training and maintain these skills through frequent use. Documentation of this training and skill must be available for review in a postpay audit.

A complete study visualizes all of the structures or organs within the anatomic description of that study and the interpretation includes comments regarding the same.

A limited study includes only a single quadrant or a possible single diagnostic problem (i.e., cholecystitis, cyst of the liver, or post void residual urine). Limited studies may be used to reevaluate a problem after the initial interpretation has been completed to clarify a finding of the initial study, but this will require the patient's return to the office/department and would not be considered as such if done during the primary encounter.

POLICY TYPE: Local Medical Review Policy

HCPCS SECTION

& BENEFIT CATEGORY: Radiology; Diagnostic Ultrasound

HCPCS CODES©: 76700-76705

HCFA'S NATIONAL POLICY:

- Title XVIII of the Social Security Act, section 1862 (a)(7). This section excludes physical examinations.

- Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services are considered to be medically reasonable and necessary.

INDICATIONS & LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

I. ABDOMINAL FLUID DETECTION - Abdominal ultrasound is very useful in the detection or confirmation of fluid in the abdominal cavity. This is most commonly performed when there is clinical suspicion of ascitic fluid. Other less common fluid collections include: Hematoma, biloma and abdominal abscess (567._, 577.9, 864.01, 864.11, 865.0_, 865.1_).

II. LIVER (V71.1, 155.0-155.2, 197.7-197.8, 570, 571._, 572.0-572.8, 782.4, 794.8) -Ultrasound is often the first diagnostic test used to evaluate the liver. The patient has generally had a physical exam and preliminary laboratory tests to include liver enzymes. Specific indications for ultrasound include:

1. Physical exam reveals hepatomegaly or signs of portal hypertension, such as ascites, spider angiomas, etc.
2. Abnormal blood tests: AST (SGOT), ALT (SGPT), GGT, alkaline phosphatase, bilirubin.
3. Suspicion of cirrhosis or diffuse hepatocellular disease. There are other uncommon clinical situations where abdominal ultrasound may be indicated. Usually, but not always, these conditions may be associated with abnormal physical findings or lab tests.
4. Suspected abscess, including pyogenic or amebic
5. Evaluation of neoplasms or liver masses
6. Suspected metastatic liver disease
7. Liver trauma
8. Diagnosis and follow-up of hepatic cysts

III. BILIARY TRACT (V71.1, 156._, 574._, 575._, 576._, 793.3) -The patient undergoing abdominal ultrasound for a suspected abnormality of the gallbladder or biliary tract will have had prior history taken, physical exam performed, and lab tests to include liver enzymes and bilirubin. This history may reveal symptoms typical of gallstones. Biliary colic is characteristically a severe pain in the right upper quadrant or epigastrium. It is constant in intensity for a duration of 30 minutes to two hours. It must always be remembered that clinical presentations may be unusual or atypical, especially in the elderly patient.

Specific indications for ultrasound are:

1. Evaluation of jaundice found on physical exam
2. Suspected gallbladder stones (history of biliary colic)
3. Suspected cholecystitis, including acalculous cholecystitis (prior physical exam performed may include upper abdominal tenderness and fever)
4. Suspected gallbladder neoplasms, including follow-up of benign lesions such as polyps
5. Evaluation of the common bile duct. Abnormalities of the common bile duct, such as stones or obstructive symptoms (i.e., abdominal pain, fever, chills or jaundice).
6. Suspected biliary neoplasm

IV. PANCREAS (V71.1, 155, 157._, 577._, 863.8, 863.9) - When abdominal ultrasound is being used to evaluate the pancreas, the patient will have had prior history, physical exam and lab tests to include serum amylase.

Specific indications include:

1. Evaluation of acute pancreatitis
2. Suspected complications of pancreatitis, including abscess and pseudocyst
3. Chronic pancreatitis
4. Pancreatic trauma
5. Pancreatic neoplasm, including adenocarcinoma, cystadenoma, islet cell tumors

V. EVALUATION OF THE GASTROINTESTINAL TRACT (159, 211._, 540._) If physical examination of the patient reveals an abdominal mass, ultrasound may be helpful to clarify the origin of the mass, as well as confirm its presence.

There are several inflammatory conditions of the GI tract where ultrasound is occasionally helpful (Crohn's disease, appendicitis, diverticulitis). Usually these diagnoses are made utilizing other clinical methods and if ultrasound is being used, the case is likely an atypical presentation and its use should be justified. Physical findings may include fever and localized abdominal tenderness. A leukocytosis may be present.

VI. VASCULAR STRUCTURES (441.02, 441.3, 441.4, 442.84, 452) - Ultrasound is useful in the suspicion of dissecting aortic aneurysms. Physical exam may reveal a pulsatile mass in the abdomen.

If an aneurysm is diagnosed, ultrasound is often used to follow the size if the patient does not undergo initial surgery.

Six month intervals are acceptable between studies. If more frequent exams are necessary, documentation should be on hand for review.

Venous vascular studies are rarely necessary but may be utilized in vena cava filter location and portal vein evaluation for patency in advanced liver disease.

VII. EVALUATION OF INTRA-ABDOMINAL CAVITY AND WALL LESIONS (567._, 756.71) - Utilized as a guide for aspiration or biopsy of intra-abdominal lesions. Prior physical examination of the patient reveals a suspected lesion within the abdominal wall.

VIII. SPLEEN - Ultrasound may be helpful in the evaluation of suspected disorders of the spleen. The patient will have undergone prior history and physical examination. (ICD-9-CM codes 289.5_, 759.0, 902.23, 902.34)

Specific indications include:

1. Detection of focal lesions
2. Suspected acute splenic infarction
3. Splenic trauma

IX. ABDOMINAL ULTRASOUND FOR THE INDICATION OF ABDOMINAL PAIN WILL BE CLOSELY MONITORED FOR ABERRANT USAGE. (789.0_, 789.1, 789.2, 789.3_, 789.4_, 789.5, 789.6_, 789.9)

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

V71.1, 155.0-155.2, 156.0-156.9, 157.0-157.9, 159.0-159.9, 195.2, 196.2, 197.7-197.8, 211.0-211.9, 228.04, 289.50-289.59, 441.02, 441.3, 441.4, 442.84, 452, 540.0-540.9, 567.0-567.9, 570, 571.0-571.9, 572.0-572.8, 574.0-574.91, 575.0-575.9, 576.0-576.9, 577.0-577.9, 756.71 (10/1997), 759.0, 782.4, 789.00-789.09, 789.1, 789.2, 789.30-789.39, 789.40-789.49, 789.5, 789.60-789.69, 789.9, 790.5, 793.3, 794.8, 863.8, 863.9, 864.01, 864.11, 865.00-856.09, 865.10-865.19, 902.23, 902.34, 998.51-998.59

All other ICD-9 codes not mentioned above will be denied.

REASONS FOR DENIAL:

There is no literature to support the efficacy of this procedure for any indications other than those listed above.

NONCOVERED ICD-9 CODES: All others not mentioned above.

SOURCES OF INFORMATION:

Physicians' Current Procedural Terminology (CPT);

This policy was developed in conjunction with our Medical Services Review Committee (02/1994) which consist of primary care and relative specialties (LAMSRC Item 94-6).

CODING GUIDELINES:

76700 - Echography, abdominal, B-scan and/or real time with image documentation; complete
76705 - Limited (eg, single organ, quadrant, follow-up

This policy does not take precedence over the Correct Coding Initiative (CCI) and CCI does not interfere with Indications/Limitations or acceptable diagnoses specified.

DOCUMENTATION REQUIREMENTS:

OTHER COMMENTS: Medicare Providers' News LAB97-06, LA96-02, LA95-07, LA95-04, LA94-10, and LA94-03

CAC NOTES:

This policy does not reflect the sole opinion of the carrier or Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee (12/1993), which includes representatives from radiology, gastroenterology, OB/GYN, and urology.

START DATE OF COMMENT PERIOD: 12/01/1993

START DATE OF NOTICE PERIOD: 11/1997
03/01/1996
11/30/1995
06/01/1995
12/01/1994
06/01/1994

EFFECTIVE DATE: 07/01/1994

REVISION DATE:

REVISION NUMBER: