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NonvascularExtremityUltrasound(L28178)

LCDforNonvascularExtremityUltrasound(L28178)

ContractorInformation

ContractorName
NationalGovernmentServices,Inc.
ContractorNumber
Number
Type
00130
FI
00131
FI
00160
FI
00332
FI
00450
FI
00452
FI
00453
FI
00630
Carrier
00660
Carrier
13101
MAC
13102
MAC
13201
MAC
13202
MAC
13282
MAC
13292
MAC
ContractorType
Carrier
FiscalIntermediary
MACPartA
MACPartB

State(s)
IN
IL
KY
OH
WI
MI
VA,WV
IN
KY
CTPartA
CTPartB
NYPartA
NYPartB
NYPartB
NYPartB

LCDInformation

LCDIDNumber
L28178

LCDTitle
NonvascularExtremityUltrasound

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Contractor'sDeterminationNumber
L28178(R4)

AMACPT/ADACDTCopyrightStatement
CPTcodes,descriptionsandotherdataonlyarecopyright2010AmericanMedical
Association(orsuchotherdateofpublicationofCPT).AllRightsReserved.Applicable
FARS/DFARSClausesApply.CurrentDentalTerminology,(CDT)(includingprocedure
codes,nomenclature,descriptorsandotherdatacontainedtherein)iscopyrightbythe
AmericanDentalAssociation.2002,2004AmericanDentalAssociation.Allrightsreserved.
ApplicableFARS/DFARSapply.

CMSNationalCoveragePolicy
LanguagequotedfromCentersforMedicareandMedicaidServices(CMS),National
CoverageDeterminations(NCDs)andcoverageprovisionsininterpretivemanualsisitalicized
throughoutthepolicy.NCDsandcoverageprovisionsininterpretivemanualsarenotsubjectto
theLocalCoverageDetermination(LCD)ReviewProcess(42CFR405.860[b]and42CFR
426[SubpartD]).Inaddition,anadministrativelawjudgemaynotreviewanNCD.See
Section1869(f)(1)(A)(i)oftheSocialSecurityAct.
Unlessotherwisespecified,italicizedtextrepresentsquotationfromoneormoreofthe
followingCMSsources:
TitleXVIIIoftheSocialSecurityAct(SSA):
TitleXVIIIoftheSocialSecurityAct,Section1862(a)(1)(A).
ThissectionstatesthatnoMedicarepaymentshallbemadeforitemsorservicesthatarenot
reasonableandnecessaryforthediagnosisortreatmentofillnessorinjury.
TitleXVIIIoftheSocialSecurityAct,Section1833(e).
ThissectionprohibitsMedicarepaymentforanyclaimthatlacksthenecessaryinformationto
processtheclaim.
CMSPublications:
CMSPublication10003,MedicareNationalCoverageDeterminationsManual,Chapter1:
220.5UltrasoundDiagnosticProcedures

CMSPublication10004,MedicareClaimsProcessingManual,Chapter7:
50BillingPartBRadiologyServicesandOtherDiagnosticProcedures

CMSPublication10004,MedicareClaimsProcessingManual,Chapter12:
70PaymentConditionsforRadiologyServices

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CMSPublication10004,MedicareClaimsProcessingManual,Chapter13:
10.1BillingPartBRadiologyServicesandOtherDiagnosticProcedures

CMSPublication10004,MedicareClaimsProcessingManual,Chapter16:
40.2PaymentLimitforPurchasedServices

PrimaryGeographicJurisdiction
Number
Type
State(s)
00130
FI
IN
00131
FI
IL
00160
FI
KY
00332
FI
OH
00450
FI
WI
00452
FI
MI
00453
FI
VA,WV
00630
Carrier
IN
00660
Carrier
KY
13101
MAC
CTPartA
13102
MAC
CTPartB
13201
MAC
NYPartA
13202
MAC
NYPartB
13282
MAC
NYPartB
13292
MAC
NYPartB

OversightRegion
RegionI,II,III,V

OriginalDeterminationEffectiveDate
Forservicesperformedonorafter07/18/2008

OriginalDeterminationEndingDate

RevisionEffectiveDate
Forservicesperformedonorafter01/01/2011

RevisionEndingDate

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NonvascularExtremityUltrasound(L28178)

IndicationsandLimitationsofCoverageand/orMedicalNecessity
Abstract:
Ultrasoundoftheextremityisanoninvasiveimagingtechniquethatuseshighfrequencysound
wavestoevaluatetheextremities(armsandlegs),providingrealtime,twodimensionalimages.
Longitudinal,transverseandobliqueimagesoftheareaofinterestareobtained.Ultrasound,
echographyandsonographyarealltermsthatmaybeusedinterchangeablytodescribethis
particularimagingtechnique.ThisLCDidentifiestheindicationsandlimitationsofMedicare
coverageandreimbursementfortheseservices.
Indications:
Extremityultrasoundisindicatedforthefollowingconditions:
1.Todetectcysts,abscesses,tumors(includingevaluationofsizeoftumors)andeffusion
2.Todistinguishsolidtumorsfromfluidfilledcysts
3.Toevaluatetendons(includingtears,tendonitisandtenosynovitis),joints,plantarfascia,
ligaments,softtissuemasses,ganglioncysts,intermetatarsalneuromaandstressfractures
ofthemetatarsals
4.Toaidinthediagnosisofandsurgicalremovalofforeignbodies.
Limitations:
1.Extremityultrasoundmustbeperformedbyqualifiedandknowledgeablephysicians
and/ortechnicians(sonographers)underthegeneralsupervisionofaphysician.
2.Extremityultrasound(CPTcodes76881or76882)islimitedtostudiesofthearmsand
legs.
3.Extremityultrasoundisnotconsideredmedicallynecessaryforthefollowingconditions:
plantarwarts
neuromas(wheretheclinicalimpressionisobviousandultrasoundisnotlikelytoadd
furtherinformation)
bunions
paronychia
superficialabscessesor
cellulitis.
4.Bilateralstudiesareallowedonlyifthereispathologyofbothextremitiesdictating
medicalnecessityfortwodistinctexaminations.Itisnotreasonableandnecessaryto
performthecontralateralextremityasa"control."
Neuromas,plantarfasciitis,superficialganglia,bursaeandabscessesunlessthereis
documentedevidenceofsomeclinicalpresentationthatobscurestheclinician'sabilityto
establishthesesimpleclinicaldiagnoses.
Inthecaseofplantarfasciitis,diagnosticultrasoundisNOTtobeusedinmakingan
initialdetermination(diagnosis)andthenshouldONLYbeusedafterafailedcourseof
conservativemanagement.Evenatthattime,itistobeusedonlyonce.
OtherComments:
ForclaimssubmittedtothefiscalintermediaryorPartAMAC:thiscoveragedetermination
alsoapplieswithinstatesoutsidetheprimarygeographicjurisdictionwithfacilitiesthathave
nominatedNationalGovernmentServicestoprocesstheirclaims.
BilltypecodesonlyapplytoproviderswhobilltheseservicestothefiscalintermediaryorPart
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AMAC.Billtypecodesdonotapplytophysicians,otherprofessionalsandsupplierswhobill
theseservicestothecarrierandPartBMAC.
Limitationofliabilityandrefundrequirementsapplywhendenialsarelikely,whetherbasedon
medicalnecessityorothercoveragereasons.Theprovider/suppliermustnotifythebeneficiary
inwriting,priortorenderingtheservice,iftheprovider/supplierisawarethatthetest,itemor
proceduremaynotbecoveredbyMedicare.Thelimitationofliabilityandrefundrequirements
donotapplywhenthetest,itemorprocedureisstatutorilyexcluded,hasnoMedicarebenefit
categoryorisrenderedforscreeningpurposes.
FordatesofservicepriortoApril1,2010,FQHCservicesshouldbereportedwithbilltype
73X.FordatesofserviceonorafterApril1,2010,billtype77Xshouldbeusedtoreport
FQHCservices.

CodingInformation

BillTypeCodes:
ContractorsmayspecifyBillTypestohelpprovidersidentifythoseBillTypestypically
usedtoreportthisservice.AbsenceofaBillTypedoesnotguaranteethatthepolicydoes
notapplytothatBillType.CompleteabsenceofallBillTypesindicatesthatcoverageis
notinfluencedbyBillTypeandthepolicyshouldbeassumedtoapplyequallytoall
claims.
011x

HospitalInpatient(IncludingMedicarePartA)

012x

HospitalInpatient(MedicarePartBonly)

013x

HospitalOutpatient

071x

ClinicRuralHealth

073x

ClinicFreestanding

077x

ClinicFederallyQualifiedHealthCenter(FQHC)

085x

CriticalAccessHospital

RevenueCodes:
ContractorsmayspecifyRevenueCodestohelpprovidersidentifythoseRevenueCodes
typicallyusedtoreportthisservice.InmostinstancesRevenueCodesarepurely
advisoryunlessspecifiedinthepolicyservicesreportedunderotherRevenueCodesare
equallysubjecttothiscoveragedetermination.CompleteabsenceofallRevenueCodes
indicatesthatcoverageisnotinfluencedbyRevenueCodeandthepolicyshouldbe
assumedtoapplyequallytoallRevenueCodes.
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Revenuecodesonlyapplytoproviderswhobilltheseservicestothefiscalintermediaryor
PartAMAC.Revenuecodesdonotapplytophysicians,otherprofessionalsandsupplierswho
billtheseservicestothecarrierorPartBMAC.
Pleasenotethatnotallrevenuecodesapplytoeverytypeofbillcode.Providersare
encouragedtorefertotheFISSrevenuecodefileforallowablebilltypes.Similarly,notall
revenuecodesapplytoeachCPT/HCPCScode.ProvidersareencouragedtorefertotheFISS
HCPCSfileforallowablerevenuecodes.
Allrevenuecodesbilledontheinpatientclaimforthedatesofserviceinquestionmaybe
subjecttoreview.
0402

OtherImagingServicesUltrasound

0972

ProfessionalFeesRadiologyDiagnostic

CPT/HCPCSCodes
CPTcode76880wasdeleted12/31/2010.
76881
ULTRASOUND,EXTREMITY,NONVASCULAR,REALTIME
WITHIMAGEDOCUMENTATIONCOMPLETE
76882

ULTRASOUND,EXTREMITY,NONVASCULAR,REALTIME
WITHIMAGEDOCUMENTATIONLIMITED,ANATOMIC
SPECIFIC

ICD9CodesthatSupportMedicalNecessity
ItistheresponsibilityoftheprovidertocodetothehighestlevelspecifiedintheICD9CM
(e.g.,tothefourthorfifthdigit).ThecorrectuseofanICD9CMcodelistedbelowdoesnot
assurecoverageofaservice.Theservicemustbereasonableandnecessaryinthespecific
caseandmustmeetthecriteriaspecifiedinthisdetermination.
171.2

MALIGNANTNEOPLASMOFCONNECTIVEANDOTHERSOFT
TISSUEOFUPPERLIMBINCLUDINGSHOULDER

171.3

MALIGNANTNEOPLASMOFCONNECTIVEANDOTHERSOFT
TISSUEOFLOWERLIMBINCLUDINGHIP

195.4

MALIGNANTNEOPLASMOFUPPERLIMB

195.5

MALIGNANTNEOPLASMOFLOWERLIMB

198.89

SECONDARYMALIGNANTNEOPLASMOFOTHERSPECIFIED
SITES

215.2

OTHERBENIGNNEOPLASMOFCONNECTIVEANDOTHER
SOFTTISSUEOFUPPERLIMBINCLUDINGSHOULDER

215.3

OTHERBENIGNNEOPLASMOFCONNECTIVEANDOTHER
SOFTTISSUEOFLOWERLIMBINCLUDINGHIP

229.8

BENIGNNEOPLASMOFOTHERSPECIFIEDSITES

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238.1

NEOPLASMOFUNCERTAINBEHAVIOROFCONNECTIVEAND
OTHERSOFTTISSUE

238.8

NEOPLASMOFUNCERTAINBEHAVIOROFOTHERSPECIFIED
SITES

239.2

NEOPLASMOFUNSPECIFIEDNATUREOFBONESOFTTISSUE
ANDSKIN

239.89

NEOPLASMSOFUNSPECIFIEDNATURE,OTHERSPECIFIED
SITES

355.6

LESIONOFPLANTARNERVE

682.3

CELLULITISANDABSCESSOFUPPERARMANDFOREARM

682.4

CELLULITISANDABSCESSOFHANDEXCEPTFINGERSAND
THUMB

682.6

CELLULITISANDABSCESSOFLEGEXCEPTFOOT

682.7

CELLULITISANDABSCESSOFFOOTEXCEPTTOES

717.5

DERANGEMENTOFMENISCUSNOTELSEWHERECLASSIFIED

719.01

EFFUSIONOFJOINTOFSHOULDERREGION

719.02

EFFUSIONOFUPPERARMJOINT

719.03

EFFUSIONOFFOREARMJOINT

719.04

EFFUSIONOFHANDJOINT

719.05

EFFUSIONOFJOINTOFPELVICREGIONANDTHIGH

719.06

EFFUSIONOFLOWERLEGJOINT

719.07

EFFUSIONOFANKLEANDFOOTJOINT

719.40

PAININJOINTSITEUNSPECIFIED

719.41

PAININJOINTINVOLVINGSHOULDERREGION

719.42

PAININJOINTINVOLVINGUPPERARM

719.43

PAININJOINTINVOLVINGFOREARM

719.44

PAININJOINTINVOLVINGHAND

719.45

PAININJOINTINVOLVINGPELVICREGIONANDTHIGH

719.46

PAININJOINTINVOLVINGLOWERLEG

719.47

PAININJOINTINVOLVINGANKLEANDFOOT

719.48

PAININJOINTINVOLVINGOTHERSPECIFIEDSITES

719.49

PAININJOINTINVOLVINGMULTIPLESITES

719.61

OTHERSYMPTOMSREFERABLETOJOINTOFSHOULDER
REGION

719.62

OTHERSYMPTOMSREFERABLETOUPPERARMJOINT

719.63

OTHERSYMPTOMSREFERABLETOFOREARMJOINT

719.64

OTHERSYMPTOMSREFERABLETOHANDJOINT

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719.65

OTHERSYMPTOMSREFERABLETOJOINTOFPELVICREGION
ANDTHIGH

719.66

OTHERSYMPTOMSREFERABLETOLOWERLEGJOINT

719.67

OTHERSYMPTOMSREFERABLETOANKLEANDFOOTJOINT

726.10

DISORDERSOFBURSAEANDTENDONSINSHOULDER
REGIONUNSPECIFIED

726.11

CALCIFYINGTENDINITISOFSHOULDER

726.12

BICIPITALTENOSYNOVITIS

726.19

OTHERSPECIFIEDDISORDERSOFBURSAEANDTENDONSIN
SHOULDERREGION

726.31

MEDIALEPICONDYLITIS

726.32

LATERALEPICONDYLITIS

726.33

OLECRANONBURSITIS

726.39

OTHERENTHESOPATHYOFELBOWREGION

726.4

ENTHESOPATHYOFWRISTANDCARPUS

726.5

ENTHESOPATHYOFHIPREGION

726.61

PESANSERINUSTENDINITISORBURSITIS

726.62

TIBIALCOLLATERALLIGAMENTBURSITIS

726.63

FIBULARCOLLATERALLIGAMENTBURSITIS

726.64

PATELLARTENDINITIS

726.65

PREPATELLARBURSITIS

726.69

OTHERENTHESOPATHYOFKNEE

726.71

ACHILLESBURSITISORTENDINITIS

726.72

TIBIALISTENDINITIS

726.73

CALCANEALSPUR

726.79

OTHERENTHESOPATHYOFANKLEANDTARSUS

726.90

ENTHESOPATHYOFUNSPECIFIEDSITE

727.01

SYNOVITISANDTENOSYNOVITISINDISEASESCLASSIFIED
ELSEWHERE

727.02

GIANTCELLTUMOROFTENDONSHEATH

727.03

TRIGGERFINGER(ACQUIRED)

727.04

RADIALSTYLOIDTENOSYNOVITIS

727.05

OTHERTENOSYNOVITISOFHANDANDWRIST

727.06

TENOSYNOVITISOFFOOTANDANKLE

727.09

OTHERSYNOVITISANDTENOSYNOVITIS

727.2

SPECIFICBURSITIDESOFTENOFOCCUPATIONALORIGIN

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727.3

OTHERBURSITISDISORDERS

727.40

SYNOVIALCYSTUNSPECIFIED

727.41

GANGLIONOFJOINT

727.42

GANGLIONOFTENDONSHEATH

727.49

OTHERGANGLIONANDCYSTOFSYNOVIUMTENDONAND
BURSA

727.51

SYNOVIALCYSTOFPOPLITEALSPACE

727.59

OTHERRUPTUREOFSYNOVIUM

727.61

COMPLETERUPTUREOFROTATORCUFF

727.62

NONTRAUMATICRUPTUREOFTENDONSOFBICEPS(LONG
HEAD)

727.63

NONTRAUMATICRUPTUREOFEXTENSORTENDONSOF
HANDANDWRIST

727.64

NONTRAUMATICRUPTUREOFFLEXORTENDONSOFHAND
ANDWRIST

727.65

NONTRAUMATICRUPTUREOFQUADRICEPSTENDON

727.66

NONTRAUMATICRUPTUREOFPATELLARTENDON

727.67

NONTRAUMATICRUPTUREOFACHILLESTENDON

727.68

NONTRAUMATICRUPTUREOFOTHERTENDONSOFFOOT
ANDANKLE

727.69

NONTRAUMATICRUPTUREOFOTHERTENDON

727.82

CALCIUMDEPOSITSINTENDONANDBURSA

727.89

OTHERDISORDERSOFSYNOVIUMTENDONANDBURSA

728.71

PLANTARFASCIALFIBROMATOSIS

728.79

OTHERFIBROMATOSESOFMUSCLELIGAMENTANDFASCIA

728.82

FOREIGNBODYGRANULOMAOFMUSCLE

728.86

NECROTIZINGFASCIITIS

728.89

OTHERDISORDERSOFMUSCLELIGAMENTANDFASCIA

729.5

PAININLIMB

729.6

RESIDUALFOREIGNBODYINSOFTTISSUE

729.81

SWELLINGOFLIMB

733.94

STRESSFRACTUREOFTHEMETATARSALS

782.2

LOCALIZEDSUPERFICIALSWELLINGMASSORLUMP

835.00

CLOSEDDISLOCATIONOFHIPUNSPECIFIEDSITE

840.3

INFRASPINATUS(MUSCLE)(TENDON)SPRAIN

840.4

ROTATORCUFF(CAPSULE)SPRAIN

840.6

SUPRASPINATUS(MUSCLE)(TENDON)SPRAIN

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840.8

SPRAINOFOTHERSPECIFIEDSITESOFSHOULDERAND
UPPERARM

840.9

SPRAINOFUNSPECIFIEDSITEOFSHOULDERANDUPPER
ARM

841.0

RADIALCOLLATERALLIGAMENTSPRAIN

841.1

ULNARCOLLATERALLIGAMENTSPRAIN

841.8

SPRAINOFOTHERSPECIFIEDSITESOFELBOWAND
FOREARM

841.9

SPRAINOFUNSPECIFIEDSITEOFELBOWANDFOREARM

842.00

SPRAINOFUNSPECIFIEDSITEOFWRIST

842.01

SPRAINOFCARPAL(JOINT)OFWRIST

842.02

SPRAINOFRADIOCARPAL(JOINT)(LIGAMENT)OFWRIST

842.09

OTHERWRISTSPRAIN

842.10

SPRAINOFUNSPECIFIEDSITEOFHAND

842.11

SPRAINOFCARPOMETACARPAL(JOINT)OFHAND

842.12

SPRAINOFMETACARPOPHALANGEAL(JOINT)OFHAND

842.13

SPRAINOFINTERPHALANGEAL(JOINT)OFHAND

842.19

OTHERHANDSPRAIN

843.8

SPRAINOFOTHERSPECIFIEDSITESOFHIPANDTHIGH

843.9

SPRAINOFUNSPECIFIEDSITEOFHIPANDTHIGH

844.0

SPRAINOFLATERALCOLLATERALLIGAMENTOFKNEE

844.1

SPRAINOFMEDIALCOLLATERALLIGAMENTOFKNEE

844.3

SPRAINOFTIBIOFIBULAR(JOINT)(LIGAMENT)SUPERIOROF
KNEE

844.8

SPRAINOFOTHERSPECIFIEDSITESOFKNEEANDLEG

844.9

SPRAINOFUNSPECIFIEDSITEOFKNEEANDLEG

845.00

UNSPECIFIEDSITEOFANKLESPRAIN

845.01

DELTOID(LIGAMENT)ANKLESPRAIN

845.02

CALCANEOFIBULAR(LIGAMENT)ANKLESPRAIN

845.03

TIBIOFIBULAR(LIGAMENT)SPRAINDISTAL

845.09

OTHERANKLESPRAIN

845.10

UNSPECIFIEDSITEOFFOOTSPRAIN

845.11

TARSOMETATARSAL(JOINT)(LIGAMENT)SPRAIN

845.12

METATARSAOPHALANGEAL(JOINT)SPRAIN

845.13

INTERPHALANGEAL(JOINT)TOESPRAIN

845.19

OTHERFOOTSPRAIN

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DiagnosesthatSupportMedicalNecessity
Notapplicable

ICD9CodesthatDONOTSupportMedicalNecessity
Notapplicable

ICD9CodesthatDONOTSupportMedicalNecessityAsteriskExplanation

DiagnosesthatDONOTSupportMedicalNecessity
Notapplicable

GeneralInformation

DocumentationRequirements
Thepatient'smedicalrecordmustcontaindocumentationthatfullysupportsthemedical
necessityforservicesincludedwithinthisLCD.(See"IndicationsandLimitationsof
Coverage.")Thisdocumentationincludes,butisnotlimitedto,relevantmedicalhistory,
physicalexamination,andresultsofpertinentdiagnostictestsorprocedures.
EachclaimmustbesubmittedwithICD9CMcodesthatreflecttheconditionofthepatient,
andindicatethereason(s)forwhichtheservicewasperformed.Claimssubmittedwithout
ICD9CMcodeswillbereturned.
Apermanentrecordoftheultrasoundanditsinterpretationshouldbekeptonfileinthe
patient'srecord.Therecordshouldincludeallofthefollowing:
Imagesofallappropriateareas,labeledwithexamdate,patientidentification,andimage
orientationand
documentationofthevariationsfromnormal,accompaniedbymeasurements
formalinterpretation.
Resultsofalltestingshouldbesharedwiththereferringphysician.
DocumentationmustbeavailabletoMedicareuponrequest.

Appendices
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Notapplicable

UtilizationGuidelines
Theperformanceofmorethantwoultrasoundsofanextremityinsixmonthsisrarely
medicallyreasonableandnecessary.
Servicesinexcessoftwotests,perextremity,insixmonths,willbeconsiderednotmedically
necessary.

SourcesofInformationandBasisforDecision
Thisbibliographypresentsthosesourcesthatwereobtainedduringthedevelopmentofthis
policy.NationalGovernmentServicesisnotresponsibleforthecontinuingviabilityofWeb
siteaddresseslistedbelow.
GerlingMC,PfirrmannCW,FarookiS,etal.Posteriortibialistendontears:comparisonofthe
diagnosticefficacyofmagneticresonanceimagingandultrasonographyforthedetectionof
surgicallycreatedlongitudinaltearsincadavers.InvestigativeRadiology.200338:5156.
HashimotoBE,KramerDJ,WiitalaL.Applicationsofmusculoskeletalsonography.Journalof
ClinicalUltrasound.199927(6):293318.
MalingSN,ThompsonCL,BecroftJ.Accuracyofultrasonographyinthediagnosisof
posteriortibialtendonpathology.
RawoolNM,Nazarian,LN.Ultrasoundoftheankleandfoot.SeminarsinUltrasound,CT,and
MRI.200021(3):276284.
RockettMS.Theuseofultrasoundinthefootandankle.JAmPodiatryMedAssoc.
199989(7):331338.
VohraPK,KincaidBR,JapourCJ,SobelE.Ultrasonographicevaluationofplantarfascia
bands.JournaloftheAmericaPodiatricMedicalAssociation.200292(8):444449.

AdvisoryCommitteeMeetingNotes
CarrierAdvisoryCommitteeMeetingDate(s):
Connecticut:01/27/2009
Indiana:01/26/2009
Kentucky:01/22/2009
NewYork:01/28/2009
Thiscoveragedeterminationdoesnotreflectthesoleopinionofthecontractororcontractor
MedicalDirector.Althoughthefinaldecisionrestswiththecontractor,thisdeterminationis
developedinconsultationwithrepresentativesfromAdvisoryCommitteemembersand/or
fromvariousstateandlocalproviderorganizations.

StartDateofCommentPeriod
01/08/2009
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EndDateofCommentPeriod
02/21/2009

StartDateofNoticePeriod
01/01/2011

RevisionHistoryNumber
R4

RevisionHistoryExplanation
R4(effective01/01/2011):DuetotheannualHCPCSupdatefor2011,CPTcode76880
wasremovedandCPTcodes76881and76882wereaddedtothefollowingstatementin
theLimitationssection:
Extremityultrasound(CPTcodes76881or76882)islimitedtostudiesofthearmsand
legs.
CPTcode76880wasdeleted12/31/2010andremovedfromthelistinginthe
CPT/HCPCSCodessectionoftheLCD.Anexplanatorynoteregardingthecode
deletionwasaddedtothissection.CPTcodes76881and76882wereaddedasthe
replacementcodes.
Minortemplatechangesweremadetoreflectcurrenttemplatelanguage.Nocomment
andnoticeperiodsrequiredandnonegiven.
R3(effective04/01/2010):BasedonCR6338,ChangeTypeofBill(TOB)forFederally
QualifiedHealthCenters(FQHCs)from73Xto77X,thefollowingparagraphhasbeenadded
totheLCD:
FordatesofservicepriortoApril1,2010,FQHCservicesshouldbereportedwithbilltype
73X.FordatesofserviceonorafterApril1,2010,billtype77Xshouldbeusedtoreport
FQHCservices.Minortemplatechangesweremadetoreflectcurrenttemplatelanguage.No
commentandnoticeperiodsrequiredandnonegiven.
R2(effective10/01/2009):AnnualupdateICD9CMcodesperCMSChangeRequest#6520,
07/10/2009.ICD9CMcode239.8deletedandICD9CMcode239.89addedtothelistof
ICD9CodesthatSupportMedicalNecessity.CMSpublicationsectionupdated.Reformatted
toreflectcurrenttemplatelanguage.Noadditionalcommentornoticeperiodsrequiredand
nonegiven.
R1(effective07/01/2009):SourceofrevisionExternal.TheexistingLCDwasresubmitted
toallNGSPartAandPartBjurisdictionsforpublicandCACcommentfrom01/08/2009
through02/21/2009.InadditiontotheJ13MACcontractsforwhichitwasalreadyineffect,
thispolicynowappliestoallNGScontractslistedunderPrimaryGeographicJurisdiction.
ThefollowingICD9CMcodeshavebeenaddedtothelistofICD9CodesthatSupport
MedicalNecessitybasedonthecommentsreceivedduringtheCommentPeriod(01/08/2009
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through02/21/2009):
171.2,171.3,215.2,215.3,238.1,239.2,719.01,719.04,719.40,719.41,719.42,719.43,
719.44,719.45,719.46,719.47,719.48,719.49,726.10,726.11,726.12,726.19,726.31,
726.32,726.33,726.39,726.4,726.5,726.61,726.62,726.63,726.64,726.65,726.69,727.01,
727.02,727.03,727.04,727.05,727.06,727.09,727.2,727.3,727.40,727.41,727.49,727.59,
727.61,727.62,727.63,727.64,727.65,727.66,727.67,727.68,727.69,727.82,727.89,
728.79,728.82,728.86,728.89,729.5,782.2,840.3,840.4,840.6,840.8,840.9,841.0,841.1,
841.8,841.9,842.00,842.01,842.02,842.09,842.10,842.11,842.12,842.13,842.19,843.8,
843.9,844.0,844.1,844.3,844.8,844.9,845.00,845.01,845.02,845.03,845.10,845.11,
845.13and845.19.
ThisLCDiseffectiveforDownstateNewYorkPartBonJuly18,2008forConnecticut
PartBonAugust1,2008forUpstateNewYorkPartBonSeptember1,2008forNewYork
andConnecticutPartAonNovember14,2008.
TheCMSStatementofWorkfortheJ13MedicareAdministrativeContract(MAC)requires
thatthecontractorretainthemostclinicallyappropriateLCDwithinthejurisdiction.This
HealthNowpolicyisbeingpromulgatedtotheJ13MACasthemostclinicallyappropriate
LCDwithinthatjurisdiction.
******************************
ThefollowingareadministrativenotesenteredbytheMedicareCoverageDatabase
Contractor:
08/08/2009ThispolicywasupdatedbytheICD920092010AnnualUpdate.
3/7/2010ThedescriptionforBillTypeCode73waschanged
8/1/2010ThedescriptionforBillTypeCode11waschanged
8/1/2010ThedescriptionforBillTypeCode12waschanged
8/1/2010ThedescriptionforBillTypeCode13waschanged
8/1/2010ThedescriptionforBillTypeCode71waschanged
8/1/2010ThedescriptionforBillTypeCode73waschanged
8/1/2010ThedescriptionforBillTypeCode85waschanged
8/1/2010ThedescriptionforRevenuecode0402waschanged
8/1/2010ThedescriptionforRevenuecode0972waschanged
11/21/2010ThefollowingCPT/HCPCScodesweredeleted:
76880wasdeletedfromGroup1

ReasonforChange
HCPCSAddition/Deletion

LastReviewedOnDate
01/01/2011

RelatedDocuments
Article(s)
https://apps.ngsmedicare.com/lcd/LCD_L28178.htm

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A48353NonvascularExtremityUltrasoundSupplementalInstructionsArticle

LCDAttachments
NonvascularExtremityUltrasoundCommentandResponse(139,376bytes)

https://apps.ngsmedicare.com/lcd/LCD_L28178.htm

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