Professional Documents
Culture Documents
LCD Retroperitoneal Ultrasound l34577 Eff June 13 2019
LCD Retroperitoneal Ultrasound l34577 Eff June 13 2019
LCD Retroperitoneal Ultrasound l34577 Eff June 13 2019
Contractor Information
CONTRACTOR NAME CONTRACT TYPE CONTRACT NUMBER JURISDICTION STATE(S)
Palmetto GBA A and B and HHH MAC 11201 - MAC A J-M South Carolina
Palmetto GBA A and B and HHH MAC 11202 - MAC B J-M South Carolina
Palmetto GBA A and B and HHH MAC 11301 - MAC A J-M Virginia
Palmetto GBA A and B and HHH MAC 11302 - MAC B J-M Virginia
Palmetto GBA A and B and HHH MAC 11401 - MAC A J-M West Virginia
Palmetto GBA A and B and HHH MAC 11402 - MAC B J-M West Virginia
Palmetto GBA A and B and HHH MAC 11501 - MAC A J-M North Carolina
Palmetto GBA A and B and HHH MAC 11502 - MAC B J-M North Carolina
LCD Information
Document Information
LCD ID Original Effective Date
L34577 For services performed on or after 10/01/2015
AMA CPT / ADA CDT / AHA NUBC Copyright Notice Period End Date
Statement 07/02/2017
CPT codes, descriptions and other data only are
copyright 2018 American Medical Association. All Rights
Reserved. Applicable FARS/HHSARS apply.
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
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.
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.
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
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.Complete absence of all
Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally
to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report
this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services
reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all
Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to
apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
Group 1 Paragraph:
N/A
Group 1 Codes:
Group 1 Paragraph:
N/A
Group 1 Codes:
N/A
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.
06/13/2019 R21
All coding located in the Coding Information section and all • Provider
verbiage regarding billing and coding under the Associated Education/Guidance
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.
10/01/2018 R20
Under ICD-10 Codes that Support Medical Necessity • Revisions Due To
Group 1: Codes the following ICD-10 codes have been ICD-10-CM Code
added: K35.20, K35.21, K35.30, K35.31, K35.32, K35.33, Changes
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.
05/10/2018 R19
Under ICD-10 Codes That Support Medical Necessity • Reconsideration
added ICD-10 codes N30.01, N30.11, N30.21, N30.31, Request
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
02/26/2018 R18 The Jurisdiction "J" Part B Contracts for Alabama (10112),
• Change in Affiliated
Georgia (10212) and Tennessee (10312) are now being
Contract Numbers
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.
01/29/2018 R17 The Jurisdiction "J" Part A Contracts for Alabama (10111),
• Change in Affiliated
Georgia (10211) and Tennessee (10311) are now being
Contract Numbers
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.
10/01/2017 R16
Under ICD-10 Codes That Support Medical Necessity • Revisions Due To
ICD-10-CM Code
Group 1: Codes deleted ICD-10 code E85.8. Under ICD-
Changes
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.
07/03/2017 R15
Under ICD-10 Codes That Support Medical Necessity • Provider
Group 1: Codes added ICD-10 codes N31.1, N31.2, Education/Guidance
• Reconsideration
N31.8, and N31.9.
Request
01/01/2017 R11 Under CPT/HCPCS Codes added CPT code 76706. This
• Provider
revision is due to the 2017 Annual CPT/HCPCS Code Update
Education/Guidance
and becomes effective 1/1/17. • Revisions Due To
CPT/HCPCS Code
Changes
Associated Documents
Attachments
N/A
Created on 07/11/2019. Page 10 of 11
Related Local Coverage Documents
Article(s)
A55336 - Billing and Coding: Retroperitoneal Ultrasound
A55546
- (MCD Archive Site)LCD(s)
DL34577
- (MCD Archive Site)
N/A
Public Version(s)
Keywords
• Retroperitoneal Ultrasound
• Ultrasound