Local Coverage Determination (LCD)

Retroperitoneal Ultrasound

L34577

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10111 - MAC A	J - J	Alabama
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10211 - MAC A	J - J	Georgia
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10311 - MAC A	J - J	Tennessee
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
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
L34577

LCD Title
Retroperitoneal Ultrasound

Proposed LCD in Comment Period
N/A

Source Proposed LCD
DL34577

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 11/07/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
05/18/2017

Notice Period End Date
07/02/2017

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.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

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.

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.

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 (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.

4. Kidneys, ureter, and bladder:

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.

7. Prostate- Evaluation of the prostate is primarily done transrectally by US.

8. Adrenal Gland- US is of little value since a CT scan is considered more accurate.

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

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code	Description
Please accept the License to see the codes.

Revenue Codes

Code	Description
Please accept the License to see the codes.

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

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.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
11/07/2019	R22	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.	Provider Education/Guidance
06/13/2019	R21	All coding located in the *Coding Information* section and all verbiage regarding billing and coding under the *Associated 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 21^stCentury 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	R20	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, 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 21^stCentury 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	R19	Under *ICD-10 Codes That Support Medical Necessity* added ICD-10 codes N30.01, N30.11, N30.21, N30.31, 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 fields included on the LCD are applicable as noted in this policy.	Reconsideration Request
02/26/2018	R18	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.	Change in Affiliated Contract Numbers
01/29/2018	R17	The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being 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.	Change in Affiliated Contract Numbers
10/01/2017	R16	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* deleted ICD-10 code E85.8. Under *ICD-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.	Revisions Due To ICD-10-CM Code Changes
07/03/2017	R15	Under *ICD-10 Codes That Support Medical Necessity Group 1: Codes* added ICD-10 codes N31.1, N31.2, N31.8, and N31.9.	Provider Education/Guidance Reconsideration Request
07/03/2017	R14	Comments were received. However, no changes were made to this LCD.	Provider Education/Guidance
03/16/2017	R13	Under *Coverage Indications, Limitations and/or Medical Necessity* deleted CPT code 76706 from the first paragraph. Under *CPT/HCPCS Group 1: Codes* deleted CPT code 76706. CPT 76706 is a new CPT effective on 1/1/17 which replaced the existing Medicare G code (G0389) that was specific to a screening ultrasound for an abdominal aortic aneurysm (AAA). Medicare has criteria outlined in the *Medicare Claims Processing Manual* which must be met in order for a beneficiary to be eligible for the AAA screening benefit. This LCD addresses only diagnostic ultrasound procedures whose criteria for coverage differ from those for the screening procedure. CPT 76706 was inadvertently added to the LCD for diagnostic ultrasound and is being removed. There is no change in coverage of either the screening or any diagnostic procedure referenced in the LCD as a result of this action. Coverage for screening ultrasound for AAA is addressed in article A55071 which was in effect prior to any changes to LCD L34577 regarding CPT 76706. Under *Associated Information- Utilization Guidelines* deleted the following verbiage from the last sentence, “…located in the *Related Local Coverage Documents* section of this LCD.”	Provider Education/Guidance
02/27/2017	R12	Under *ICD-10 Codes That Support Medical Necessity* deleted ICD-10 codes C45.1, C48.1, C48.2, C86.2, C86.3, R10.0, R10.13, R10.84, R11.2, R19.03, R19.04, R19.05, R19.06, R19.07, R19.09, S36.81XA, S36.81XD, and S36.81XS.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
01/01/2017	R11	Under *CPT/HCPCS Codes* added CPT code 76706. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
10/31/2016	R10	Under *Coverage Indications, Limitations and/or Medical Necessity* verbiage was revised for clarification for the first, second, and third paragraphs and for statements #2 and #4(b). Under *Related Local Coverage Documents* added the Retroperitoneal Ultrasound Coding and Billing Article A55336.	Provider Education/Guidance Other
10/31/2016	R9	Under *CPT/HCPCS Group 1: Codes* deleted CPT codes 76700 and 76705 as these codes are not specific to retroperitoneal ultrasound but are standard abdominal ultrasounds which include an examination of the retroperitoneal structures. This revision is retroactive to 10/01/2015.	Provider Education/Guidance Other
10/24/2016	R8	Under *ICD-10 Codes that Support Medical Necessity Group 1: Codes* added R74.0, R74.8, R10.11 and R10.12 as these codes were inadvertently omitted in the ICD-10 transition to the current LCD. These codes are effective on or after October 01, 2015.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
10/01/2016	R7	Under *ICD-10 Codes That Support Medical Necessity* added D47.Z2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.81, N13.0, R31.21, R31.29, R93.41, R93.421, R93.422, R93.429, R93.49, R83.011A, T83.011D, T83.011S, T83.012A, T83.012D, T83.012S, T83.021A, T83.021D, T83.021S, T83.022A, T83.022D, T83.022S, T83.032A, T83.032D, T83.032S, T83.512A, T83.512D, T83.512S, T83.592A, T83.592D, T83.592S, T83.714A, T83.714D, T83.714S, T83.722A, T83.722D, T83.722S, T83.723A, T83.723D, T83.723S, T83.724A, T83.724D, T83.724S, D49.511, D49.512, D49.519, D49.59, I97.620, I97.621, I97.622, I97.638, I97.648, Q25.42, Q25.43, and Q25.44. Under *ICD-10 Codes That Support Medical Necessity* deleted K85.3, K86.8, K85.0, K85.2, K85.9, K85.1, K85.8, R31.2, and R93.4. Under *ICD-10 Codes That Support Medical Necessity* code descriptions were revised for C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, N10, N40.0, and N40.1. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
09/08/2016	R6	Under *Associated Information- Utilization Guidelines* for clarification purposes, verbiage was added related to when a full abdominal ultrasound might be required and for coding instructions for screening procedures.	Provider Education/Guidance
09/01/2016	R5	Under *ICD-10 Codes that Support Medical Necessity* added K56.3, K80.00, K80.01, K80.10, K80.11, K80.12, K80.13, K80.18, K80.19, K80.20, K80.21, K80.60, K80.61, K80.62, K80.63, K80.64, K80.65, K80.66, K80.67, K80.70, K80.71, K82.0, K82.1, K82.2, K82.3, K82.4, Q44.0, Q44.1 and R11.2.	Provider Education/Guidance Reconsideration Request Revisions Due To ICD-10-CM Code Changes
07/21/2016	R4	Under Coverage Indications, Limitations and/or Medical Necessity added the word “the” in front of the word “detection” in 3. Under *4. Kidneys, ureter and bladder* the verbiage was revised for a(i) and (iii), b and c for clarification purposes. Under 8. added the words “a computed tomography” in front of the abbreviation “CT” and added the word “the” in front of the word “evaluation” in 9. Under *CPT/HCPCS Codes* added CPT codes 76700 and 76705 due to a Reconsideration Request.	Provider Education/Guidance Reconsideration Request Other (Verbiage changes made for clarification.)
10/01/2015	R3	Under Coverage Indications, Limitations and/or Medical Necessity under number 2, removed “the” from the description and made a few formatting revisions. Under ICD-10 Codes that support Medical Necessity, removed “C64.9” as C64.1 and C64.2 are the correct coding locations for this diagnosis. Under Associated Information removed “J11”.	Provider Education/Guidance Typographical Error Other (Annual validation)
10/01/2015	R2	Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.	Other (Bill type and/or revenue code removal)
10/01/2015	R1	Under *Associated Information-Documentation Requirements* corrected the sentence to read, “Documentation supporting medical necessity should be legible, maintained in the patient's medical record, and must be made available to the J11 A/B MAC upon request.” Under *Sources of Information and Basis for Decision* corrected the spelling of “Harrison’s” in the following: Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison’s Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;1998.	Provider Education/Guidance Typographical Error Other

Associated Documents

Attachments
N/A

Updated On	Effective Dates	Status
10/29/2019	11/07/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Retroperitoneal Ultrasound
Ultrasound

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Retroperitoneal Ultrasound

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Note History

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LCD Information

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Coverage Guidance

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ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Keywords

Page Help for LCD - Retroperitoneal Ultrasound (L34577)

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