RETIRED Local Coverage Determination (LCD)

Nonobstetric Pelvic Ultrasound

L37636

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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.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L37636
Original ICD-9 LCD ID
Not Applicable
LCD Title
Nonobstetric Pelvic Ultrasound
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 02/26/2018
Revision Effective Date
For services performed on or after 10/24/2019
Revision Ending Date
04/22/2024
Retirement Date
04/22/2024
Notice Period Start Date
12/14/2017
Notice Period End Date
02/25/2018

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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.

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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

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.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Indications

 Pelvic pain undiagnosed by standard exam:

  1. Dysmenorrhea
  2. Menorrhagia
  3. Metrorrhagia
  4. Menometrorrhagia
  5. Postmenopausal bleeding
  6. Abnormal pelvic examination
  7. Further evaluation of abnormality found on other imaging studies
  8. Cancer

Limitations 

The accuracy of ultrasonographic studies depends on the knowledge, skills and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation of such for possible audit. Further, ultrasonographic studies must be either (1) performed by persons with appropriate training that have demonstrated minimum entry level competency by being credentialed by a nationally recognized credentialing organization in ultrasound technology (e.g., American Registry of Radiologic Technologists (ARRT) in sonography), (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in ultrasonography.

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

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

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

Documentation Requirements 

  1. The medical record must contain clear documentation of medical necessity for performing pelvic ultrasonography (e.g., history, physical findings and/or laboratory/imaging studies).
  2. A permanent record of the sonographic examination and its interpretation must be in the patient's record and made available to Medicare upon request.
Sources of Information

Consultations with the representatives to the Carrier Advisory Committee.

Other Medicare Carriers’ LCDs.

Bibliography

American College of Radiology (ACR). Practice Guideline for the Performance of Ultrasound in Females. Accessed on 6/17/2019.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
04/22/2024 R7

This LCD is being retired due to accepted standards of practice which have rendered this policy ineffective.

  • LCD Being Retired
10/24/2019 R6

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. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Nonobstetric Pelvic Ultrasound A56671 article. 

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
07/04/2019 R5

All coding located in the Coding Information section has been moved into the related Billing and Coding: Nonobstetric Pelvic Ultrasound A56671 article and removed from the LCD. 

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Nonobstetric Pelvic Ultrasound A56671 article. 

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
07/04/2019 R4

Under Sources of Information added “Consultations with the representatives to the Carrier Advisory Committee” and “Other Medicare Carriers’ LCDs”. Under Bibliography changes were made to citations to reflect AMA citation guidelines and removed “Consultations with the representatives to the Carrier Advisory Committee” and “Other Medicare Carriers’ LCDs”. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. CPT® was inserted throughout the LCD where applicable.

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 R3

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes the following ICD-10 codes have been deleted: K35.2 and T81.4XXA. 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, N35.016, N35.116, N35.812, N35.813, N35.814, N35.816, N35.819, N35.82, N35.912, N35.913, N35.914, N35.916, N35.919, N35.92, N99.116, O86.00, O86.01, O86.02, O86.03, O86.04, O86.09, Q51.20, Q51.21, Q51.22, Q51.28, 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 R2

Under ICD-10 Codes That Support Medical Necessity added ICD-10 codes N30.01, N30.11, N30.21, N30.31, N30.41, N30.81, N30.91, N83.00, N83.01, N83.02, N83.10, N83.11, N83.12, N83.201, N83.202, N83.291 and N83.292. 

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
  • Reconsideration Request
02/26/2018 R1

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.

  • Other
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56671 - Billing and Coding: Nonobstetric Pelvic Ultrasound
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
04/22/2024 10/24/2019 - 04/22/2024 Retired You are here
10/14/2019 10/24/2019 - N/A Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Ultrasound
  • Pelvic Ultrasound
  • Nonobstetric Pelvic Ultrasound

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