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National Coverage Determination (NCD)

Ultrasound Diagnostic Procedures

220.5

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Tracking Information

Publication Number
100-3
Manual Section Number
220.5
Manual Section Title
Ultrasound Diagnostic Procedures
Version Number
1
Effective Date of this Version
This is a longstanding national coverage determination. The effective date of this version has not been posted.
Ending Effective Date of this Version
05/17/2007
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)
Inpatient Hospital Services
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Ultrasound diagnostic procedures utilizing low energy sound waves are being widely employed to determine the composition and contours of nearly all body tissues except bone and air-filled spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a wide variety of conditions.
Indications and Limitations of Coverage

Ultrasound diagnostic procedures are listed below and are divided into two categories:

  1. Medicare coverage is extended to the procedures listed in Category I. Periodic claims review by the intermediary's medical consultants should be conducted to insure that the techniques are medically appropriate and the general indications specified in these categories are met.
  2. Techniques in Category II are considered experimental and should not be covered at this time.

Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and nuclear medicine diagnostic technique):

  • Echoencephalography, (Diencephalic Midline) (A-Mode).
  • Echoencephalography, Complete (Diencephalic Midline and Ventricular Size).
  • Ocular and Orbital Echography (A-Mode).
  • Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an artificial lens (pseudophakoi) following cataract surgery.
  • Ocular and Orbital Sonography (B-Mode).
  • Echocardiography, Pericardial Effusion (M-Mode).
  • Pericardiocentesis, by Ultrasonic Guidance.
  • Echocardiography, Cardiac Valve(s) (M-Mode).
  • Echocardiography, Complete (M-Mode).
  • Echocardiography, limited (e.g., follow-up or limited study) (M-Mode).
  • Pleural Effusion Echography.
  • Thoracentesis, by Ultrasonic Guidance.
  • Abdominal Sonography, complete survey study (B-Scan).
  • Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan).
  • Abdominal sonography is not synonymous with ultrasound examination of individual organs.
  • Renal Cyst Aspiration, by Ultrasonic Guidance.
  • Renal Biopsy, by Ultrasonic Guidance.
  • Pancreas Sonography (B-Scan).
  • Pancreatic sonography has proven effective in diagnosing pseudocysts.
  • Spleen Sonography (B-Scan).
  • Abdominal Aorta Echography (A-Mode).
  • Abdominal Aorta Sonography (B-Scan).
  • Retroperitoneal Sonography (B-Scan).
  • Retroperitoneal sonography does not include planning of fields for radiation therapy.
  • Urinary Bladder Sonography (B-Scan).
  • Urinary bladder sonography does not include staging of bladder tumors.
  • Pregnancy Diagnosis sonography (B-Scan).
  • Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan).
  • Fetal Growth Rate Sonography (B-Scan).
  • Placenta Localization Sonography (B-Scan).
  • Pregnancy Sonography, Complete (B-Scan).
  • Molar Pregnancy Diagnosis Sonography (B-Scan).
  • Ectopic Pregnancy Diagnosis sonography (B-Scan).
  • Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus).
  • Intrauterine Contraceptive Device Sonography (B-Scan).
  • Pelvic Mass Diagnosis Sonography (B-Scan).
  • Amniocentesis, by Ultrasonic Guidance.
  • Arterial Flow Study, Peripheral (Doppler).
  • Venous Flow Study, Peripheral (Doppler).
  • Arterial Aneurysm, Peripheral (B-Scan).
  • Radiation Therapy Planning Sonography (B-Scan).
  • Thyroid Echography (A-Mode).
  • Thyroid Sonography (B-Scan).
  • Breast Echography (A-Mode).
  • Breast Sonography (B-Scan).
  • Hepatic Sonography (B-Scan).
  • Gallbladder Sonography.
  • Renal Sonography.
  • Two-Dimensional Echocardiography (B-Mode).

Category II - (Clinical reliability and efficacy not proven):

  • B-Scan for atherosclerotic narrowing of peripheral arteries.
  • Monitoring of cardiac output (Doppler).

In view of the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic procedures other than those listed under Categories I and II should be carefully reviewed before payment. Medical justification may be required. When appropriate, new uses for ultrasound diagnostic procedures should be forwarded to CMS so that revisions may be made in the coverage policy when appropriate.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
Revision History
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Ultrasound Diagnostic Procedures 3 05/22/2007 - N/A View
Ultrasound Diagnostic Procedures 2 05/17/2007 - 05/22/2007 View
Ultrasound Diagnostic Procedures 1 01/01/1966 - 05/17/2007 You are here
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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