3D Interpretation and Reporting of Imaging Studies

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for 3D interpretation reporting of imaging studies. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for 3D interpretation reporting of imaging studies and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 Requirements for Ordering and Following Orders for Diagnostic Tests.
• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, 100-03, Chapter 1, Part 2, Section 160.24 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease, Part 4, Section 220.1 Computed Tomography (CT) and Section 220.2 Magnetic Resonance Imaging (MRI).
• CMS IOM 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD.

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physician examinations.
• Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Federal Registration References:

• 42 CFR 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
• 42 CFR 410.33 Independent diagnostic testing facility

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Covered Indications

The advent of multi-slice imaging and enhanced imaging techniques has allowed for the generation of 3D images. Applications of this technology include the visualization of inflammatory and neoplastic lesions, imaging of facial malformations, complex facial fracture/trauma, urographic, biliary and other indications. As the indications may be varied and the diagnoses for the base service vast, the companion billing and coding article, A56526, will outline diagnosis codes to be added to the claim to attest that all of the criteria outlined in this LCD have been met by the provider.

3D Imaging is used for Deep Brain Stimulation for lead placement. This indication will be covered if all criteria set out in NCD 160.24 are met. Please refer to Local Coverage Article: Billing and Coding: 3D Interpretation and Reporting of Imaging Studies (A56526), for all coding information

This LCD does not apply to 3D vascular imaging in conjunction with magnetic resonance angiography (MRA) NCD 220.3 or computed tomography angiography (CTA) NCD 220.1 and their respective CPT codes, whose coverage is otherwise specified via the NCD process.

Limitations

1. In freestanding and independent diagnostic testing facilities, Medicare expects the referring physician to generate an appropriate written request indicating the clinical need for the additional 3D imaging, that a copy of that request be maintained by the interpreting physician and the interpreting physician’s report addresses those specific clinical issues. In the event that a 3D interpretation is deemed urgently needed by the radiologist and the referring physician is not immediately available, the radiologist must document the time of the study, the specific need for the study, and a summary of the findings that were urgently transmitted to the practitioner named as the referring physician on the radiology report.
   
   
2. 3D rendering with interpretation and reporting of computed tomography (CT), magnetic resonance (MR) imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation and 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation may be considered medically unnecessary and denied if equivalent information obtained from the test has already been provided by another procedure (magnetic resonance imaging, ultrasound, angiography,etc.) or could be provided by a standard CT scan (two-dimensional) without reconstruction.
   
   
3. Medicare expects that no more than 20 percent of the total CT and MR imaging of any practice be submitted with 3D rendering or interpretation, with or without image post-processing. However, for cancer evaluation applications, such as staging/monitoring for pulmonary metastases, this threshold may be often exceeded. Therefore, if data suggests providers are billing at higher rates for other indications for 3D rendering, then Medical Review may do pre- or post-pay reviews to validate the use and medical necessity of the test.
   
   
4. All imaging studies will be subject to the American College of Radiology (ACR) Guidelines for reporting.
   
   
5. 3D rendering with interpretation and reporting of CT, MR imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation can be reported when 3D rendering is performed by a radiologist or a specially-trained technologist at the acquisition scanner. However, 3D rendering, with interpretation and reporting of CT, MR imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation is reported when the 3D post-processing images are reconstructed on an independent workstation with concurrent physician supervision. In order to report 3D rendering, with interpretation and reporting of CT, MR imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation, the supervising physician must provide concurrent supervision.

In order to report the correct CPT code for the 3D analysis, it should be documented within the radiology report as to whether the 3D was performed on an independent workstation or on the acquisition scanner. Making an explicit statement within the radiology report will avoid ambiguity, and aid the coder in accurately coding for the 3D reconstruction. Some practices may separately document this in the patient’s electronic medical record, but not actually in the report.

Imaging studies are complex with thousands of individual pictures. Beyond identifying a fracture in an emergency setting a discussion of treatment planning after the patient has left the department is common. 3D may be necessary to understand the anatomy for treatment planning. This discussion occurs after the acute event. Another vignette is an imaging study for stroke but later a seizure concern is identified subsequent to the emergency visit and 3D is applied to evaluate an anatomy of the hippocampus for a seizure focus.

Notice:  Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, 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.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.

N/A

N/A

Refer to Local Coverage Article: Billing and Coding: 3D Interpretation and Reporting of Imaging Studies (A56526), for all coding information.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the medical record must be legible and include appropriate patient identification (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.
3. 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.
4. The medical record documentation must support the medical necessity of the services as stated in this policy.
5. Use of one of the secondary diagnosis codes in the companion article, Billing and Coding: 3D Interpretation and Reporting of Imaging Studies (A56526) implies medical necessity for 3D rendering and interpretation.
6. Documentation supporting medical necessity must be maintained in the medical record along with the written request for the study from the referring physician.
7. 3D Reconstruction services are to be reported by a separate report or in a separate section of the base service report.
8. The site of service for the 3D Reconstruction (if different from the facility billing the base service) and the time of the services should be noted in the report.
9. A permanent archive of 3D studies of CTA studies is suggested by the ACR.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

L32602, 3D Interpretation and Reporting of Imaging Studies, Novitas Solutions Jurisdiction H Local Coverage Determination

Requirements for Ordering and Following Orders for Diagnostic Tests

Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease

Reasonable and Necessary Provision in an LCD

Other Contractor Policies

Contractor Medical Directors

Original JH ICD-9 Source LCD L34709, 3D Interpretation and Reporting of Imaging Studies

http://www.acr.org/Advocacy/Economics-Health-Policy/Billing-Coding/Coding-Source-List/2003/Jul-Aug-2003/Further-Clarification-on-the-Ordering-of-Diagnostic-Tests-Rule