LCD Reference Article Billing and Coding Article

Billing and Coding: Transrectal Ultrasound

A57427

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Contractor Information

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General Information

Source Article ID
N/A
Article ID
A57427
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Transrectal Ultrasound
Article Type
Billing and Coding
Original Effective Date
10/10/2019
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Publications:

CMS Publication 100-03, Medicare National Coverage Determinations Manual (NCD) Manual, Chapter 1:

    220.5 Ultrasound Diagnostic Procedures

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9:

    100 General Billing Requirements

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12:

    70 Payment Conditions for Radiology Services

Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Transrectal Ultrasound.

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation must be available to Medicare upon request.

Utilization Guidelines:

CPT code 76872 will be covered only 2 (two) times in a year. Services exceeding this parameter will be considered not medically necessary.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(118 Codes)
Group 1 Paragraph

The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in the determination.

CPT code 76872

Group 1 Codes
Code Description
A18.14 Tuberculosis of prostate
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.1 Malignant neoplasm of anal canal
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C45.1 Mesothelioma of peritoneum
C48.0 Malignant neoplasm of retroperitoneum
C48.1 Malignant neoplasm of specified parts of peritoneum
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C61 Malignant neoplasm of prostate
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.8 Malignant neoplasm of overlapping sites of bladder
C78.5 Secondary malignant neoplasm of large intestine and rectum
C79.51 Secondary malignant neoplasm of bone
C79.52 Secondary malignant neoplasm of bone marrow
C79.82 Secondary malignant neoplasm of genital organs
D01.1 Carcinoma in situ of rectosigmoid junction
D01.2 Carcinoma in situ of rectum
D01.3 Carcinoma in situ of anus and anal canal
D07.5 Carcinoma in situ of prostate
D12.7 Benign neoplasm of rectosigmoid junction
D12.8 Benign neoplasm of rectum
D12.9 Benign neoplasm of anus and anal canal
D29.1 Benign neoplasm of prostate
D37.1 Neoplasm of uncertain behavior of stomach
D37.2 Neoplasm of uncertain behavior of small intestine
D37.3 Neoplasm of uncertain behavior of appendix
D37.4 Neoplasm of uncertain behavior of colon
D37.5 Neoplasm of uncertain behavior of rectum
D40.0 Neoplasm of uncertain behavior of prostate
K50.014 Crohn's disease of small intestine with abscess
K50.114 Crohn's disease of large intestine with abscess
K50.814 Crohn's disease of both small and large intestine with abscess
K60.311 Anal fistula, simple, initial
K60.312 Anal fistula, simple, persistent
K60.313 Anal fistula, simple, recurrent
K60.321 Anal fistula, complex, initial
K60.322 Anal fistula, complex, persistent
K60.323 Anal fistula, complex, recurrent
K60.411 Rectal fistula, simple, initial
K60.412 Rectal fistula, simple, persistent
K60.413 Rectal fistula, simple, recurrent
K60.421 Rectal fistula, complex, initial
K60.422 Rectal fistula, complex, persistent
K60.423 Rectal fistula, complex, recurrent
K60.511 Anorectal fistula, simple, initial
K60.512 Anorectal fistula, simple, persistent
K60.513 Anorectal fistula, simple, recurrent
K60.521 Anorectal fistula, complex, initial
K60.522 Anorectal fistula, complex, persistent
K60.523 Anorectal fistula, complex, recurrent
K61.0 Anal abscess
K61.1 Rectal abscess
K61.2 Anorectal abscess
K61.31 Horseshoe abscess
K61.39 Other ischiorectal abscess
K61.4 Intrasphincteric abscess
K62.0 Anal polyp
K62.1 Rectal polyp
K62.5 Hemorrhage of anus and rectum
K62.7 Radiation proctitis
K62.82 Dysplasia of anus
K62.89 Other specified diseases of anus and rectum
N40.0 Benign prostatic hyperplasia without lower urinary tract symptoms
N40.1 Benign prostatic hyperplasia with lower urinary tract symptoms
N40.2 Nodular prostate without lower urinary tract symptoms
N40.3 Nodular prostate with lower urinary tract symptoms
N41.0 Acute prostatitis
N41.1 Chronic prostatitis
N41.2 Abscess of prostate
N41.3 Prostatocystitis
N41.4 Granulomatous prostatitis
N41.8 Other inflammatory diseases of prostate
N42.30 Unspecified dysplasia of prostate
N42.31 Prostatic intraepithelial neoplasia
N42.32 Atypical small acinar proliferation of prostate
N42.39 Other dysplasia of prostate
N42.81 Prostatodynia syndrome
N42.82 Prostatosis syndrome
N42.83 Cyst of prostate
N42.89 Other specified disorders of prostate
N46.01 Organic azoospermia
N46.021 Azoospermia due to drug therapy
N46.022 Azoospermia due to infection
N46.023 Azoospermia due to obstruction of efferent ducts
N46.024 Azoospermia due to radiation
N46.025 Azoospermia due to systemic disease
N46.029 Azoospermia due to other extratesticular causes
N46.11 Organic oligospermia
N46.121 Oligospermia due to drug therapy
N46.122 Oligospermia due to infection
N46.123 Oligospermia due to obstruction of efferent ducts
N46.124 Oligospermia due to radiation
N46.125 Oligospermia due to systemic disease
N46.129 Oligospermia due to other extratesticular causes
N46.8 Other male infertility
N50.1 Vascular disorders of male genital organs
N53.11 Retarded ejaculation
N53.13 Anejaculatory orgasm
N53.14 Retrograde ejaculation
N53.19 Other ejaculatory dysfunction
R15.0 Incomplete defecation
R15.1 Fecal smearing
R15.2 Fecal urgency
R15.9 Full incontinence of feces
R36.1 Hematospermia
R97.20 Elevated prostate specific antigen [PSA]
R97.21 Rising PSA following treatment for malignant neoplasm of prostate
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z12.12 Encounter for screening for malignant neoplasm of rectum
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Z85.46 Personal history of malignant neoplasm of prostate

Group 2

(1 Code)
Group 2 Paragraph

CPT code 76873

Group 2 Codes
Code Description
C61 Malignant neoplasm of prostate
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Code Description

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N/A

Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R2

Due to the annual ICD-10 code updates, ICD-10 codes K60.3, K60.4 and K60.5 have been deleted from Group 1 in the ICD-10-CM Codes that Support Medical Necessity section and the following codes have been added: K60.311, K60.312, K60.313, K60.321, K60.322, K60.323, K60.411, K60.412, K60.413, K60.421, K60.422, K60.423, K60.511, K60.512, K60.513, K60.521, K60.522 and K60.523.

11/30/2023 R1

Updated to indicate the article is an LCD Reference Article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33578 - Transrectal Ultrasound
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Public Versions
Updated On Effective Dates Status
09/18/2024 10/01/2024 - N/A Currently in Effect You are here
11/20/2023 11/30/2023 - 09/30/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Prostate