This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33256 3D Interpretation and Reporting of Imaging Studies provides billing and coding guidance for 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 the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding Guidelines
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- For non-hospital based outpatient services, the medical record documentation maintained by the ordering/referring physician/non-physician 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.
- 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 /non-physician 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 upon request.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L33256 3D Interpretation and Reporting of Imaging Studies may be monitored and addressed through post payment data analysis and subsequent medical review audits.
