Local Coverage Determination (LCD)

Nonvascular Extremity Ultrasound

L33619

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33619
Original ICD-9 LCD ID
Not Applicable
LCD Title
Nonvascular Extremity Ultrasound
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/01/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (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 Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Title XVIII of the Social Security Act, Section 1862(a)(1)(A).
This section states that no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e).
This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

CMS Publications:

CMS Publication 100-03,Medicare National Coverage Determinations Manual(NCD), Chapter 1:

    220.5 Ultrasound Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 7:

    50 Billing Part B Radiology Services and Other Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    70 Payment Conditions for Radiology Services

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13:

    10.1 Billing Part B Radiology Services and Other Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 16:

    40.2 Payment Limit for Purchased Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:

Ultrasound of the extremity is a non-invasive imaging technique that uses high-frequency sound waves to evaluate the extremities (arms and legs), providing real-time, two-dimensional images. Longitudinal, transverse and oblique images of the area of interest are obtained. Ultrasound, echography and sonography are all terms that may be used interchangeably to describe this particular imaging technique. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.

Indications:

Extremity ultrasound is indicated for the following conditions:

  1. To detect cysts, abscesses, tumors (including evaluation of size of tumors) and effusion;
  2. To distinguish solid tumors from fluid-filled cysts;
  3. To evaluate tendons (including tears, tendonitis and tenosynovitis), joints, plantar fascia, ligaments, soft tissue masses, ganglion cysts, intermetatarsal neuroma and stress fractures of the metatarsals;
  4. To aid in the diagnosis of and surgical removal of foreign bodies.

Limitations:

  1. Extremity ultrasound must be performed by qualified and knowledgeable physicians and/or technicians (sonographers) under the general supervision of a physician.
  2. Extremity ultrasound is limited to studies of the arms and legs.
  3. Extremity ultrasound is considered not medically necessary for the routine diagnosis or management of the following conditions:
    - bunions;
    - cellulitis;
    - neuromas (where the clinical impression is obvious and ultrasound is not likely to add further information);
    - paronychia;
    - plantar warts; or
    - superficial abscesses.
  4. Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a "control."
  5. Extremity ultrasound is considered not medically necessary for diagnosis or management of neuromas, superficial ganglia, bursae and abscesses unless there is documented evidence of some clinical presentation that obscures the clinician's ability to establish these simple clinical diagnoses.
  6. Extremity ultrasound is considered not medically necessary in the initial determination (diagnosis) of plantar fasciitis. A single diagnostic extremity ultrasound may be medically necessary for plantar fasciitis when the diagnosis is still uncertain after a failed course of conservative management. Repeated extremity ultrasound is not medically necessary in plantar fasciitis.
  7. Extremity ultrasound of the same extremity more than two times in six months is rarely medically reasonable and necessary (see the “Documentation Requirements” and “Utilization Guidelines” sections below).
Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below.

Gerling MC, Pfirrmann CW, Farooki S, et al. Posterior tibialis tendon tears: comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers. Investigative Radiology. 2003;38:51-56.

Hashimoto BE, Kramer DJ, Wiitala L. Applications of musculoskeletal sonography. Journal of Clinical Ultrasound. 1999;27(6):293-318.

Rawool NM, Nazarian, LN. Ultrasound of the ankle and foot. Seminars in Ultrasound, CT, and MRI. 2000;21(3):276-284.

Rockett MS. The use of ultrasound in the foot and ankle. J Am Podiatry Med Assoc. 1999;89(7):331-338.

Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands. Journal of the America Podiatric Medical Association. 2002;92(8):444-449.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/01/2019 R7

This LCD was converted to the new "no-codes" format. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
08/01/2019 R6

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56787. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
01/01/2019 R5

Based on the CPT/HCPCS annual update, the descriptions for the following codes have been changed: 76881 and 76882.

DATE (01/01/2019): At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R4 Due to the annual ICD-10-CM code update for 2017, ICD-10-CM codes M25.541 and M25.542 were added to the "ICD-10-CM Codes that Support Medical Necessity" section of the LCD.
  • Revisions Due To ICD-10-CM Code Changes
08/01/2016 R3 Revised the “Limitations” section for clarity.
  • Provider Education/Guidance
10/01/2015 R2 Minor template language change.
  • Other
10/01/2015 R1 ICD-10-CM codes were added for the 7th character for D=Subsequent encounter for fracture with routine healing, G=Subsequent encounter for fracture with delayed healing, K=Subsequent encounter for fracture with nonunion, P=Subsequent encounter for fracture with malunion and S=sequela, where the 7th character, A=initial encounter, was already included.
  • Revisions Due To ICD-10-CM Code Changes
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56787 - Billing and Coding: Nonvascular Extremity Ultrasound
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
09/17/2019 10/01/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Clot

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