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Date Printed: April 22, 2018: 05:42 PM

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04-70450-24

Original Effective Date: 09/15/09

Reviewed: 02/22/18

Revised: 03/15/18

Subject: Computed Tomography (CT) Extremity (Upper and Lower)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Computed tomography (CT) is a radiologic modality that provides clinical information in the detection, differentiation and demarcation of disease. CT is a form of medical imaging that involves the exposure of members to ionizing radiation. CT should only be performed under the supervision of a physician with training in radiation protection to optimize examination safety. Radiation exposure should be taken into account when considering the use of this technology. This guideline addresses the use of CT of the extremity (upper & lower) for evaluation, diagnosis and management of extremity (upper & lower) related conditions in the outpatient setting.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography (CT) of the extremity (upper and lower) and imaging results (e.g., images, clinical reports) should be maintained in the member’s medical record. Documentation may be requested as part of the review process.

Upper Extremity

Computed tomography (CT) of the upper extremity (hand, wrist, elbow, long bone, or shoulder) meets the definition of medical necessity for the following (plain radiographies must precede CT evaluation):

Evaluation of suspicious mass/tumor (unconfirmed cancer diagnosis)

Initial evaluation of suspicious mass/tumor found on an imaging study and needing clarification or found by physical exam and remains non-diagnostic after x-ray or ultrasound is completed.

Suspected tumor size increase or recurrence based on a sign, symptom, imaging study or abnormal lab value.

Surveillance: One follow-up exam if initial evaluation is indeterminate and lesion remains suspicious for cancer. No further surveillance unless tumor is specified as highly suspicious, or change was found on last imaging.

Evaluation of known cancer

Initial staging of known cancer in the upper extremity.

Follow-up of known cancer of member undergoing active treatment within the past year.

Known cancer with suspected upper extremity metastasis based on a sign, symptom, imaging study or abnormal lab value.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

For evaluation of known or suspected infection or inflammatory disease: (e.g. osteomyelitis) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

With abnormal physical, laboratory, and/or imaging findings.

Known or suspected (based upon initial workup including imaging) septic arthritis or osteomyelitis.

For evaluation of suspected avascular necrosis (AVN) (e.g., aseptic necrosis) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

High suspicion for AVN (e.g. corticosteroid use, transplant recipients) with negative plain films.

For evaluation of known or suspected autoimmune disease, (e.g. rheumatoid arthritis) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

Imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g. rheumatoid factor (RF), antinuclear antibody (ANA), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), cyclic citrullinated peptide (CCP)).

For evaluation of known or suspected fracture and/or injury

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

Suspected fracture when imaging is negative or equivocal.

Determine position of known fracture fragments/dislocation.

Evaluate for delayed union or non-union of fracture or joint fusion.

For evaluation of persistent pain and initial imaging has been performed and MRI is contraindicated or cannot be performed

Chronic (lasting 3 months or greater) pain and/or persistent tendonitis unresponsive to conservative treatment*, within the last 6 months which includes active medical therapy (physical therapy or chiropractic treatments) and/or physician supervised exercise** of at least four (4) weeks; OR

With progression or worsening of symptoms during the course of conservative treatment.

Pre-operative evaluation

Pre-operative evaluation for planned surgery of complex fractures and/or dislocations

Post-operative/procedural evaluation

When imaging, physical, or laboratory findings indicate joint infection, delayed or non-healing, or other surgical/procedural complications.

Additional indications for an upper extremity (hand, wrist, arm, elbow, or shoulder) CT

Bone scan, ultrasound, or x-ray is non-diagnostic or requires further evaluation.

CT arthrogram and MRI is contraindicated or cannot be performed.

To assess status of osteochondral abnormalities including osteochondral fractures, osteochondritis dissecans, or treated osteochondral defects where physical or imaging findings suggest its presence and MRI is contraindicated or cannot be performed.

Known or suspected partial or complete tendon rupture and MRI is contraindicated or cannot be performed.

Additional indications for shoulder CT

For any evaluation of member with shoulder prosthesis or other implanted metallic hardware where prosthetic loosening or dysfunction is suspected on physical examination or imaging.

Evaluation of recurrent dislocation and MRI is contraindicated or cannot be performed.

For evaluation of brachial plexus dysfunction (brachial plexopathy/thoracic outlet syndrome) and MRI is contraindicated or cannot be performed.

For evaluation of known or suspected rotator cuff tear, or labral tear (SLAP lesion, Bankart lesion) and MRI is contraindicated or cannot be performed.

Impingement or rotator cuff tear indicated by positive Neer’s sign, Hawkin’s sign or drop sign and MRI is contraindicated or cannot be performed.

Status post prior rotator cuff repair with suspected re-tear and findings on prior imaging are indeterminate and MRI is contraindicated or cannot be performed.

Additional indications for wrist CT when MRI is contraindicated or cannot be performed

For evaluation of suspected ligament injury with evidence of wrist instability on examination or evidence of joint space widening on x-ray.

For suspected triangular fibrocartilage complex (TFCC) injury

To differentiate between occult ganglion and synovitis in chronic dorsal wrist pain.

Lower Extremity

Computed tomography (CT) of the lower extremity (ankle, foot, hip, or knee) meets the definition of medical necessity for the following:

Evaluation of suspicious mass/tumor (unconfirmed cancer diagnosis)

Initial evaluation of suspicious mass/tumor found on an imaging study and needing clarification or found by physical exam and remains non-diagnostic after x-ray or ultrasound is completed.

Suspected tumor size increase or recurrence based on a sign, symptom, imaging study or abnormal lab value.

Surveillance: One follow-up exam if initial evaluation is indeterminate and lesion remains suspicious for cancer. No further surveillance unless tumor is specified as highly suspicious, or change was found on last imaging.

Evaluation of known cancer

Initial staging of known cancer in the upper extremity.

Follow-up of known cancer of member undergoing active treatment within the past year.

Known cancer with suspected lower extremity metastasis based on a sign, symptom, imaging study or abnormal lab value.

Cancer surveillance: Active monitoring for recurrence as clinically indicated.

For evaluation of known or suspected infection or inflammatory disease: (e.g. osteomyelitis) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

With abnormal physical, laboratory, and/or imaging findings.

Known or suspected (based upon initial workup including imaging) septic arthritis or osteomyelitis.

For evaluation of suspected avascular necrosis (AVN) (e.g., aseptic necrosis, Legg-Calve-Perthes disease in children) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

High suspicion for AVN (e.g. corticosteroid use, transplant recipients) with negative plain films.

For evaluation of known or suspected autoimmune disease, (e.g. rheumatoid arthritis) and MRI is contraindicated or cannot be performed

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

Imaging of a single joint for diagnosis or response to therapy after plain films and appropriate lab tests (e.g. rheumatoid factor (RF), antinuclear antibody (ANA), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), cyclic citrullinated peptide (CCP)).

For evaluation of known or suspected fracture and/or injury

Further evaluation of an abnormality or non-diagnostic findings on prior imaging.

Suspected fracture when imaging is negative or equivocal.

Determine position of known fracture fragments/dislocation.

For evaluation of persistent pain and initial imaging has been performed and MRI is contraindicated or cannot be performed

Chronic (lasting 3 months or greater) pain and/or persistent tendonitis unresponsive to conservative treatment*, within the last 6 months which includes active medical therapy (physical therapy or chiropractic treatments) and/or physician supervised exercise** of at least four (4) weeks; OR

With progression or worsening of symptoms during the course of conservative treatment.

Pre-operative evaluation

Pre-operative evaluation for planned surgery of complex fractures and/or dislocations

Post-operative/procedural evaluation

When imaging, physical, or laboratory findings indicate joint infection, delayed or non-healing, or other surgical/procedural complications.

Additional indications for lower extremity (foot, ankle, knee, leg, or leg) CT

Bone scan, ultrasound, or x-ray is non-diagnostic or requires further evaluation.

For evaluation of leg length discrepancy when physical deformities of the lower extremities would prevent standard modalities such as x-rays or a Scanogram from being performed. (Scanogram (CPT code 77073); bone length study is available as an alternative to lower extremity CT evaluation for leg length discrepancy).

CT arthrogram and MRI is contraindicated or cannot be performed.

To assess status of osteochondral abnormalities including osteochondral fractures, osteochondritis dissecans, or treated osteochondral defects where physical or imaging findings suggest its presence and MRI is contraindicated or cannot be performed.

Additional indications specifically for foot or ankle CT

Chronic (lasting 3 months or greater) pain in a child or an adolescent with painful rigid flat foot where imaging is unremarkable or equivocal or on clinician’s decision to evaluate for known or suspected tarsal coalition.

Accompanied by physical findings of ligament damage such as an abnormal drawer test of the ankle or significant laxity on valgus or varus stress testing and/or joint space widening on x-ray, and MRI is contraindicated or cannot be performed.

Additional indications specifically for knee CT and MRI is contraindicated or cannot be performed

Accompanied by blood in the joint (hemarthrosis) demonstrated by aspiration.

Presence of a joint effusion.

Accompanied by physical findings of a meniscal injury determined by physical examination tests (e.g. McMurray’s, Apley’s, or Thessaly’s).

Accompanied by physical findings of anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) ligamentous injury determined by the drawer test, pivot shift test, or the Lachman test.

Accompanied by physical findings of medial collateral ligament (MCL) or lateral collateral.

Additional indications specifically for hip CT

For any evaluation of member with hip prosthesis or other implanted metallic hardware where prosthetic loosening or dysfunction is suspected on physical examination or imaging.

For evaluation of total hip arthroplasty patients with suspected loosening and/or wear or osteolysis or assessment of bone stock is needed.

For evaluation of suspected slipped capital femoral epiphysis with non-diagnostic or equivocal imaging and MRI is contraindicated or cannot be performed.

Suspected labral tear of the hip with signs of clicking and pain with hip motion especially with hip flexion, internal rotation and adduction which can also be associated with locking and giving way sensations of the hip on ambulation and MRI is contraindicated or cannot be performed.

*Conservative Therapy: (musculoskeletal)

Should include a multimodality approach consisting of a combination of active and inactive components. Inactive components such as rest, ice, heat, modified activities, medical devices, (such as crutches, immobilizer, metal braces, orthotics, rigid stabilizer or splints, etc and not to include neoprene sleeves), medications, injections (bursal, and/or joint, not including trigger point), and diathermy, can be utilized. Active modalities may consist of physical therapy, a physician supervised home exercise program, and/or chiropractic care.

**Home Exercise Program (HEP)

The following two elements are required to meet guidelines for completion of conservative therapy:

Information provided on exercise prescription/plan AND

Follow up with member with information provided regarding completion of HEP (after suitable 4 week period), or inability to complete HEP due to physical reason- i.e. increased pain, inability to physically perform exercises. (Patient inconvenience or noncompliance without explanation does not constitute “inability to complete” HEP).

BILLING/CODING INFORMATION:

CPT Coding:

73200

Computed tomography, upper extremity; without contrast material

73201

Computed tomography, upper extremity; with contrast material(s)

73202

Computed tomography, upper extremity; without contrast material, followed by contrast material(s) and further sections

73700

Computed tomography, lower extremity; without contrast material

73701

Computed tomography, lower extremity; with contrast material(s)

73702

Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections

76380

Computed tomography, limited or localized follow-up study

REIMBURSEMENT INFORMATION:

Reimbursement for computed tomography (73200 – 73202 and 73700 – 73702, 76380) performed on the same anatomical area is limited to two (2) computed tomography (73200 – 73202 and 73700 – 73702, 76380) within a 6-month period. Computed tomography (73200 – 73202 and 73700 – 73702, 76380) in excess of two (2) computed tomography (73200 – 73202 and 73700 – 73702, 76380) within a 6-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Reimbursement for computed tomography (73200 – 73202 and 73700 – 73702, 76380) for an oncologic condition undergoing active treatment or active treatment completed within the previous 12 months on the same anatomical area is limited to four (4) computed tomography (73200 – 73202 and 73700 – 73702, 76380) within a 12-month period. Computed tomography (73200 – 73202 and 73700 – 73702, 76380) for an oncologic condition in excess of four (4) computed tomography (73200 – 73202 and 73700 – 73702, 76380) within a 12-month period are subject to medical review of documentation to support medical necessity. Documentation should include radiology reason for study, radiology comparison study-date and time, radiology comparison study observation, radiology impression, and radiology study recommendation.

Re-imaging or additional imaging of the extremity (upper and lower) due to poor contrast enhanced exam or technically limited exam is the responsibility of the imaging provider.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for computed tomography (CT) of the extremity (upper and lower).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology reason for study

18785-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study-date and time

18779-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology comparison study observation

18834-2

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-study observation

18782-3

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology-impression

19005-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology study-recommendation (narrative)

18783-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Coverage for the radiology services referenced in this guideline performed and billed in an outpatient or office location will be handled through the Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to member's contract benefits.

Federal Employee Plan (FEP): FEP is excluded from the National Imaging Associates (NIA) review; follow FEP guidelines.

Medicare Advantage products:

No Local Coverage Determination (LCD) was found at the time of the last guideline reviewed date.

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Computed Tomography, (220.1) located at cms.gov

DEFINITIONS:

Chronic: persisting over a long period of time.

Laxity: slackness or looseness; a lack of tautness, firmness, or rigidity. Slackness or displacement (whether normal or abnormal) in the motion of a joint.

Legg-Calve-Perthes disease: osteochondrosis of the capitular epiphysis of the femur.

Occult: obscure; concealed from observation; difficult to understand.

Osteochondritis: inflammation of both bone and cartilage.

Osteochondrosis: a disease of the growth or ossification centers in children that begins as degeneration or necrosis and is followed by regeneration or recalcification.

Slipped femoral capital epiphysis: dislocation of the epiphysis of a bone, as of the epiphysis of the head of the femur.

Tarsal coalition: the fibrous, cartilaginous, or bony fusion of two or more of the tarsal bones, often resulting in talipes planovalgus, although other deformities occur and some patients are asymptomatic; it may be congenital or acquired as a response to trauma, infection, or joint disease.

Tendonitis: inflammation of tendons and of tendon-muscle attachments.

Union: the process of healing; the renewal of continuity in a broken bone or between the edges of a wound.

Valgus stress: a pressure applied to the leg that tires to bend the lower leg sideways at the knee, away from the other leg.

Varus stress: a pressure applied to the leg that tires to bend the lower leg sideways at the knee, toward the other leg.

RELATED GUIDELINES:

Computed Tomography to Detect Coronary Artery Calcification, 04-70450-02
Computed Tomographic Angiography (CTA), 04-70450-03

Computerized Axial Tomography (CT), Head/Brain 04-70450-18

Computerized Axial Tomography (CT), Temporal Bone/Mastoid & Maxillofacial 04-70450-19

Computerized Axial Tomography (CT), of the Neck for Soft Tissue Evaluation 04-70450-20

Computerized Axial Tomography (CT), Thorax 04-70450-21

Computerized Axial Tomography (CT) Abdomen and Pelvis 04-70450-22

Computerized Axial Tomography (CT), Spine (Cervical, Thoracic, Lumbar) 04-70450-23

Whole Body Computed Tomography (CT) Scanning, 04-70450-25

OTHER:

Other name used to report computed tomography (CT):

CAT scanning

Pediatric Examinations

The use of CT in pediatric examinations requires assessment of the risks, benefits and use of the studies. The lowest possible radiation dose consistent with acceptable diagnostic image quality should be used in pediatric examinations. Radiation doses should be determined periodically based on a reasonable sample of pediatric examinations. Technical factors should be appropriate for the size and the age of the child and should be determined with consideration of parameters (e.g., characteristics of the imaging system, organs in the radiation field, lead shielding).

REFERENCES:

  1. American College of Radiology Appropriateness Criteria: Acute Hand and Wrist Trauma, 2013.
  2. American College of Radiology (ACR) Appropriateness Criteria Shoulder Pain-Traumatic, Revised 2017.
  3. American College of Radiology Appropriateness Criteria: Acute Shoulder Pain, 2014.
  4. American College of Radiology Appropriateness Criteria: Acute Trauma to the Foot. Last review date: 2014.
  5. American College of Radiology Appropriateness Criteria: Acute Trauma to the Knee. Last review date 2014.
  6. American College of Radiology Appropriateness Criteria: Avascular Necrosis (Osteonecrosis) of the Hip. Last review date 2015.
  7. American College of Radiology Appropriateness Criteria: Chronic Ankle Pain Revised 2017.
  8. American College of Radiology Appropriateness Criteria: Chronic Elbow Pain. Last review date: 2015.
  9. American College of Radiology Appropriateness Criteria: Chronic Hip Pain. Revised 2016.
  10. American College of Radiology Appropriateness Criteria: Chronic Wrist Pain, Revised 2017.
  11. American College of Radiology Appropriateness Criteria: Imaging After Knee Arthroplasty,Revised 2017.
  12. American College of Radiology Appropriateness Criteria: Primary Bone Tumors. Last review date: 2013.
  13. American College of Radiology Appropriateness Criteria: Soft-Tissues Masses, Revised 2017.
  14. Buckwalter KA, Rydberg J, Kopecky KK et al. Musculoskeletal imaging with multislice CT. American Journal of Roentgenology 2001; 176: 979-986.
  15. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  16. Fayad LM, Johnson P, Fishman EK. Multidetector CT of musculoskeletal disease in the pediatric patient: principles, techniques, and clinical applications. Radiographics 2005; 25: 603-618.
  17. Mutschler C, Vande Berg BC, Lecouvet FE et al. Postoperative meniscus: assessment at dual-detector row spiral CT arthrography of the knee. Radiology 2003; 228: 635-641.
  18. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  19. National Imaging Associates, Inc. Clinical GuidelinesUpper Extremity CT (Hand, Wrist, Elbow, Long Bone or Shoulder) 2018.
  20. National Imaging Associates, Inc. Clinical Guidelines Lower Extremity CT (Ankle, Foot, Hip or Knee), 2018.
  21. Pretorius ES, Fishman EK. Volume-rendered three-dimensional spiral CT: musculoskeletal applications. Radiographics 1999; 19: 1143-1160.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/22/18.

GUIDELINE UPDATE INFORMATION:

09/15/09

New Medical Coverage Guideline.

01/01/10

Revised BCBSF Radiology Management program exception section.

09/15/11

Scheduled review; no change in position statements. Added 76380. Revised limitation to two (2) within a 6-month period. Updated references.

10/01/11

Revision; formatting changes.

05/15/12

Revised and expanded position statement for upper and lower extremity: added tumor evaluation (bone), evaluation for fracture, fracture or subluxation with trauma, determine position of known fracture or subluxation, assessment of fracture healing for delayed union or non-union, evaluation of: auto immune disease, shoulder (impingement, rotator cuff tear, labral tear). Revised and expanded position statement for other: added statement for contraindication for MRI and when guideline criteria are met, abnormal physical findings, brachial plexus dysfunction and recurrent dislocation. Deleted but is not limited to. Updated references.

10/15/13

Scheduled review; MCG subject changed to “Computed Tomography (CT) Extremity (Upper and Lower)”. Updated program exceptions and reference sections.

01/01/15

Scheduled review; added osteochondral abnormalities. Added limitation statement for an oncologic condition; limited to four (4) computed tomography within a 12-month period. Updated references.

03/15/18

Revision; revised position statement (upper and lower extremity). MCG subject: Changed “Computerized” to “Computed” and removed “Axial”. Updated definitions and references.

Date Printed: April 22, 2018: 05:42 PM