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Retroperitoneal Ultrasound (DL34577) Page 1 of 46
PROPOSED/DRAFT Local Coverage
Retroperitoneal Ultrasound (DL34577)
Please Note: This view is an approximation of the CMS MCD LCD Detail page.
ICD-10 codes R74.0, R74.8, R10.11 and R10.12 will be added to this draft LCD when it is finalized due to a reconsideration request that was received on the current active LCD.
Please Note: This is a Proposed/Draft policy. Proposed/Draft LCDs are works in progress that are available on the Medicare Coverage
Database site for public review. Proposed/Draft LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Contract Type Contract Number
A and B and HHH MAC
11201 J - M South Carolina
A and B and HHH MAC
11301 J - M Virginia
A and B and HHH MAC
11401 J - M West Virginia
A and B and HHH MAC
11501 J - M North Carolina
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Retroperitoneal Ultrasound (DL34577) Page 2 of 46
Proposed/Draft LCD Information
Source LCD ID L34577
Proposed/Draft LCD ID DL34577
Proposed/Draft LCD Title Retroperitoneal Ultrasound
AMA CPT / ADA CDT / AHA NUBC Copyright
Statement CPT only copyright 2002-2016 American
Medical Association. All rights reserved.
CDT only copyright 2016 American Dental Association. All rights reserved.
UB-04 Manual. OFFICIAL UB-04 DATA
SPECIFICATIONS MANUAL, 2014, is
copyrighted by American Hospital Association
("AHA"), Chicago, Illinois. No portion of
OFFICIAL UB-04 MANUAL may be
reproduced, sorted in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without prior express,
written consent of AHA. Health Forum
reserves the right to change the copyright notice from time to time upon written notice to
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
Retroperitoneal Ultrasound (DL34577) Page 3 of 46
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 studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur in the retroperitoneum.
A complete study visualizes all the structures or organs within the anatomic description of that study. A limited study involves a single quadrant or a single diagnostic problem or an evaluation of an organ of interest.
Retroperitoneal ultrasonography may be considered reasonable and necessary for the diagnosis and treatment of the following areas:
2. Abdominal aorta - Ultrasound is accurate for aortic measurement and may be used to follow patients with aneurysms.
3. Inferior vena cava- Ultrasound is useful in the detection of invasion by adjacent tumors and identification of obstruction levels.
4. Kidneys, ureter, and bladder:
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 ultrasound, especially in their mid-portions. Renal ultrasound 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. Ultrasound has no role
Retroperitoneal Ultrasound (DL34577) Page 4 of 46
in vesicle ureteral reflux.
c) Bladder- Tumors of the bladder are most efficiently followed by cystoscopy and urography. However, ultrasound 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- Ultrasound 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- CT is far more accurate than ultrasound in detecting and delineating adenopathy. Ultrasound 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 ultrasound.
8. Adrenal Gland- Ultrasound is of little value since a computed tomography (CT) scan is considered more accurate.
9. Organs located in the retroperitoneal region-Ultrasound may be helpful in the evaluation of wounds, contusions, and lacerations of organs located in the retroperitoneal region.
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Proposed/Draft Process 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.
If the physical exam has primary findings for the involvement of non-retroperitoneal structures/organs (gallbladder, liver, spleen, common bile duct, etc.), even though it may be necessary to visualize retroperitoneal structures in the course of the procedure, a full abdominal ultrasound would be required in most cases to be diagnostic, and that is the procedure that should be performed and billed.
For screening coding instructions, refer to the Once in a Lifetime Abdominal Aortic
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Aneurysm (AAA) Screening Article A55071 located in the Related Local
Coverage Documents section of this LCD. Sources of Information and Basis for Decision Clemente CD, ed. Anatomy, A Regional Atlas of the Human Body. Baltimore-Munich:
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.
Open Meetings/Part B MAC Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting Type Meeting State(s) Meeting Information
10/13/2016 Open Meeting North Carolina Durham
10/13/2016 CAC Meeting North Carolina Durham
Comment Period Start Date 10/13/2016 Comment Period End Date 11/28/2016 Released to Final LCD Date Not yet released. Reason for Proposed LCD Provider Education/Guidance Other: Proposed Contact Part A Policy PO Box 100238 AG-275 Columbia, South Carolina 29202-3238 [email protected]
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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.
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Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this s