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Date Printed: August 18, 2017: 10:29 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-70450-04

Original Effective Date: 11/15/13

Reviewed: 04/23/15

Revised: 06/15/15

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Computed Tomography Angiography (CTA) Abdomen and Pelvis

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 angiography (CTA) is an imaging procedure performed for characterizing vascular anatomy, diagnosing vascular diseases, planning treatment for vascular disease and assessing the effectiveness of vascular treatment. CTA may be performed with or without contrast material.

Abdomen and pelvis CTA is used in the evaluation of the arteries and veins in the peritoneal cavity (abdominal aorta, iliac arteries). Abdomen CTA is used in the evaluation of the arteries of the abdominal aorta and renal arteries. Pelvis CTA is used in the evaluation of veins and arteries of the pelvis or lower extremities. Abdominal arteries CTA are used in the evaluation of the abdominal aorta and vascular supply to the lower extremities.

POSITION STATEMENT:

Documentation Requirements

Documentation containing the medical necessity of the computed tomography angiography (CTA) of the (abdomen and pelvis, abdomen, pelvis, and abdominal arteries) 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.

Computed tomography angiography (CTA) of the abdomen and pelvis, abdominal, pelvis and abdominal arteries meets the definition of medical necessity for the following:

Abdomen/Pelvis CTA

Indications for Abdomen/Pelvis CTA:

Evaluation of known or suspected abdominal vascular disease:

Pre-operative evaluation:

Post- operative evaluation:

Abdomen CTA

Indications for Abdomen CTA:

For evaluation of known or suspected abdominal vascular disease:

Post-operative evaluation:

Post-operative or post-procedure evaluation:

Pelvis CTA

Indications for Pelvis CTA:

Evaluation of known or suspected vascular disease:

Pre-operative evaluation:

Abdominal Arteries CTA

Indications for abdominal arteries CTA:

For evaluation of known or suspected abdominal vascular disease:

Pre-operative evaluation:

Post-operative or post-procedural evaluation:

BILLING/CODING INFORMATION:

CPT Coding:

72191

Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74174

Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing

74175

Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and image postprocessing

75635

Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

Re-imaging or additional imaging 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 angiography (CTA) of the (abdomen and pelvis, abdomen, pelvis, and abdominal arteries).

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 BCBSF Radiology Management program for select products. The National Imaging Associates (NIA) will determine coverage for these services for select products. Refer to the 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 National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Computed Tomography Angiography (CTA) Brain (Head), 04-70450-05
Computed Tomography Angiography (CTA) Neck, 04-70450-06

Computed Tomography Angiography (CTA) Chest (non coronary), 04-70450-07

Computed Tomography Angiography (CTA) Upper Extremity, 04-70450-08

Computed Tomography Angiography (CTA) Lower Extremity, 04-70450-09

OTHER:

None applicable.

REFERENCES:

  1. ACR-NASCI-SIR-SPR Practice Guideline for the Performance and Interpretation of Body Computed Tomography Angiography (CTA), 2014.
  2. American College of Radiology (ACR) Appropriateness Criteria® Abdominal Aortic Aneurysm: Interventional Planning and Follow-up, 2012.
  3. American College of Radiology ACR Appropriateness Criteria®: Imaging of Mesenteric Ischemia, 2012.
  4. American College of Radiology (ACR) Appropriateness Criteria® Clinical Condition: Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm, 2012.
  5. National Imaging Associates, Inc. CT Angiography Abdomen and Pelvis Clinical Guideline, 2015.
  6. National Imaging Associates, Inc. CT Angiography Abdomen Clinical Guideline, 2015.
  7. National Imaging Associates, Inc. CT Angiography, Pelvis Clinical Guideline, 2015.
  8. National Imaging Associates, Inc. CT Angiography, Abdominal Arteries Clinical Guideline, 2015.
  9. Rooke TW, Hirsch AT, Misra S et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124: 2020-2045.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/23/15.

GUIDELINE UPDATE INFORMATION:

11/15/13

New Medical Coverage Guideline.

01/01/14

Review. Revised and added abdomen/pelvis, abdomen, pelvis and abdominal arteries indications.

05/15/15

Annual review; revised position statement. Updated references.

06/15/15

Updated related guidelines.

Date Printed: August 18, 2017: 10:29 AM