Local Coverage Determination (LCD)

Retroperitoneal Ultrasound

L34577

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Contractor Information

LCD Information

Document Information

LCD ID
L34577
LCD Title
Retroperitoneal Ultrasound
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34577
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/07/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
05/18/2017
Notice Period End Date
07/02/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, 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.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.

CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.2

CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §220.5

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur within the retroperitoneum. A complete retroperitoneal US study visualizes all the structures or organs within the anatomic description of that study. A limited study involves an imaging of only a single quadrant, a single diagnostic problem, or an evaluation of a specific organ of interest. Retroperitoneal ultrasonography may be considered reasonable and necessary for the diagnosis and treatment of the following organs and retroperitoneal structures:

1. Pancreas

2. Abdominal aorta- US is accurate for aortic measurement and may be used to follow patients with aortic aneurysms.

3. Inferior vena cava - US is useful in the detection of invasion by adjacent tumors and identification of obstruction levels.

4. Kidneys, ureter, and bladder:

       a) Kidneys-

          i) May confirm scarred or small kidneys in chronic renal cortical disease (but may be of no use in detecting early or mild cortical disorders or to categorize specific types of cortical diseases).

          ii) May be useful in detecting and following renal cysts and localizing solid masses.

          iii) May be useful as a primary diagnostic tool in patients with suspected renal disease.

       b) Ureter- Normal ureters are usually not well visualized by US, especially in their mid-portions. Renal US is the primary mode of diagnosis of a renal obstruction  which is demonstrated by dilated ureters. It may be helpful in identifying filling defects or a mass, in its most proximal or distal portions. US has no role in vesicular ureteral reflux.        

       c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, US is useful in following intraluminal bladder tumors with or without  extraluminal extension, including evaluation of bladder wall thickness and irregularity and evaluating post void residual at the bedside. 

5. Renal transplants- US is indicated to detect urinary obstruction, fluid collection, and complications of renal transplants and is considered a primary tool in this endeavor. The presence or absence of signs and symptoms dictate utilization frequency of this modality for renal transplants.

6. Adenopathy- Computed tomography (CT) is far more accurate than US in detecting and delineating adenopathy. US in this instance should be considered secondary and rarely utilized in the detection or follow up of nodal disease.

7. Prostate- Evaluation of the prostate is primarily done transrectally by US.

8. Adrenal Gland- US is of little value since a CT scan is considered more accurate.

9. Organs located in the retroperitoneal region- US may be helpful in the evaluation of wounds, contusions, and lacerations of organs located in the retroperitoneal region.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.


Sources of Information
N/A
Bibliography

Clemente CD. Anatomy, A Regional Atlas of the Human Body. 2nd ed. Baltimore MD: Urban and Schwarzenberg;1981.

Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison's Principles of Internal Medicine.14th ed. New York, NY: McGraw-Hill;1998.

 

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
11/07/2019 R22

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision.

  • Provider Education/Guidance
06/13/2019 R21

All coding located in the Coding Information section and all verbiage regarding billing and coding under the Associated Information section has been moved into the related Billing and Coding: Retroperitoneal Ultrasound A55336 article and removed from the LCD. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD.

At this time 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.

  • Provider Education/Guidance
10/01/2018 R20

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes the following ICD-10 codes have been added: K35.20, K35.21, K35.30, K35.31, K35.32, K35.33, K35.890, K35.891, K61.31, K61.39, K61.5, K82.A1, K82.A2, K83.01, K83.09, R82.991, R82.992, R82.993, R82.994, R93.811, R93.812, R93.813, R93.89, T81.40XA, T81.40XD, T81.40XS, T81.41XA, T81.41XD, T81.41XS, T81.42XA, T81.42XD, T81.42XS, T81.43XA, T81.43XD, T81.43XS, T81.44XA, T81.44XD, T81.44XS, T81.49XA, T81.49XD, T81.49XS. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

At this time 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 ICD-10-CM Code Changes
05/10/2018 R19

Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes N30.01, N30.11, N30.21, N30.31, N30.41, N30.81 and N30.91.

At this time 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.

  • Reconsideration Request
02/26/2018 R18 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R17 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R16

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes deleted ICD-10 code E85.8. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes E85.81, E85.82, E85.89, Q53.111, Q53.112, Q53.211 and Q53.212. This revision is due to the 2017 Annual ICD-10 Code Updates.

At this time 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 ICD-10-CM Code Changes
07/03/2017 R15

 Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 codes N31.1, N31.2, N31.8, and N31.9.


 

  • Provider Education/Guidance
  • Reconsideration Request
07/03/2017 R14 Comments were received. However, no changes were made to this LCD.
  • Provider Education/Guidance
03/16/2017 R13 Under Coverage Indications, Limitations and/or Medical Necessity deleted CPT code 76706 from the first paragraph. Under CPT/HCPCS Group 1: Codes deleted CPT code 76706. CPT 76706 is a new CPT effective on 1/1/17 which replaced the existing Medicare G code (G0389) that was specific to a screening ultrasound for an abdominal aortic aneurysm (AAA). Medicare has criteria outlined in the Medicare Claims Processing Manual which must be met in order for a beneficiary to be eligible for the AAA screening benefit. This LCD addresses only diagnostic ultrasound procedures whose criteria for coverage differ from those for the screening procedure. CPT 76706 was inadvertently added to the LCD for diagnostic ultrasound and is being removed. There is no change in coverage of either the screening or any diagnostic procedure referenced in the LCD as a result of this action. Coverage for screening ultrasound for AAA is addressed in article A55071 which was in effect prior to any changes to LCD L34577 regarding CPT 76706. Under Associated Information- Utilization Guidelines deleted the following verbiage from the last sentence, “…located in the Related Local Coverage Documents section of this LCD.”
  • Provider Education/Guidance
02/27/2017 R12 Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 codes C45.1, C48.1, C48.2, C86.2, C86.3, R10.0, R10.13, R10.84, R11.2, R19.03, R19.04, R19.05, R19.06, R19.07, R19.09, S36.81XA, S36.81XD, and S36.81XS.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
01/01/2017 R11 Under CPT/HCPCS Codes added CPT code 76706. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/31/2016 R10 Under Coverage Indications, Limitations and/or Medical Necessity verbiage was revised for clarification for the first, second, and third paragraphs and for statements #2 and #4(b). Under Related Local Coverage Documents added the Retroperitoneal Ultrasound Coding and Billing Article A55336.
  • Provider Education/Guidance
  • Other
10/31/2016 R9 Under CPT/HCPCS Group 1: Codes deleted CPT codes 76700 and 76705 as these codes are not specific to retroperitoneal ultrasound but are standard abdominal ultrasounds which include an examination of the retroperitoneal structures. This revision is retroactive to 10/01/2015.
  • Provider Education/Guidance
  • Other
10/24/2016 R8 Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added R74.0, R74.8, R10.11 and R10.12 as these codes were inadvertently omitted in the ICD-10 transition to the current LCD. These codes are effective on or after October 01, 2015.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R7 Under ICD-10 Codes That Support Medical Necessity added D47.Z2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.81, N13.0, R31.21, R31.29, R93.41, R93.421, R93.422, R93.429, R93.49, R83.011A, T83.011D, T83.011S, T83.012A, T83.012D, T83.012S, T83.021A, T83.021D, T83.021S, T83.022A, T83.022D, T83.022S, T83.032A, T83.032D, T83.032S, T83.512A, T83.512D, T83.512S, T83.592A, T83.592D, T83.592S, T83.714A, T83.714D, T83.714S, T83.722A, T83.722D, T83.722S, T83.723A, T83.723D, T83.723S, T83.724A, T83.724D, T83.724S, D49.511, D49.512, D49.519, D49.59, I97.620, I97.621, I97.622, I97.638, I97.648, Q25.42, Q25.43, and Q25.44. Under ICD-10 Codes That Support Medical Necessity deleted K85.3, K86.8, K85.0, K85.2, K85.9, K85.1, K85.8, R31.2, and R93.4. Under ICD-10 Codes That Support Medical Necessity code descriptions were revised for C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, N10, N40.0, and N40.1. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
09/08/2016 R6 Under Associated Information- Utilization Guidelines for clarification purposes, verbiage was added related to when a full abdominal ultrasound might be required and for coding instructions for screening procedures.
  • Provider Education/Guidance
09/01/2016 R5 Under ICD-10 Codes that Support Medical Necessity added K56.3, K80.00, K80.01, K80.10, K80.11, K80.12, K80.13, K80.18, K80.19, K80.20, K80.21, K80.60, K80.61, K80.62, K80.63, K80.64, K80.65, K80.66, K80.67, K80.70, K80.71, K82.0, K82.1, K82.2, K82.3, K82.4, Q44.0, Q44.1 and R11.2.
  • Provider Education/Guidance
  • Reconsideration Request
  • Revisions Due To ICD-10-CM Code Changes
07/21/2016 R4 Under Coverage Indications, Limitations and/or Medical Necessity added the word “the” in front of the word “detection” in 3. Under 4. Kidneys, ureter and bladder the verbiage was revised for a(i) and (iii), b and c for clarification purposes. Under 8. added the words “a computed tomography” in front of the abbreviation “CT” and added the word “the” in front of the word “evaluation” in 9. Under CPT/HCPCS Codes added CPT codes 76700 and 76705 due to a Reconsideration Request.
  • Provider Education/Guidance
  • Reconsideration Request
  • Other (Verbiage changes made for clarification.)
10/01/2015 R3 Under Coverage Indications, Limitations and/or Medical Necessity under number 2, removed “the” from the description and made a few formatting revisions.
Under ICD-10 Codes that support Medical Necessity, removed “C64.9” as C64.1 and C64.2 are the correct coding locations for this diagnosis.
Under Associated Information removed “J11”.
  • Provider Education/Guidance
  • Typographical Error
  • Other (Annual validation)
10/01/2015 R2 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R1 Under Associated Information-Documentation Requirements corrected the sentence to read, “Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the J11 A/B MAC upon request.” Under Sources of Information and Basis for Decision corrected the spelling of “Harrison’s” in the following: Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison’s Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;1998.
  • Provider Education/Guidance
  • Typographical Error
  • Other

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
10/29/2019 11/07/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Retroperitoneal Ultrasound
  • Ultrasound

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