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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.

04-70450-24

Original Effective Date: 09/15/09

Reviewed: 12/04/14

Revised: 01/01/15

Subject: Computerized Axial 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 and Lower Extremity

Computed tomography (CT) of the extremity (upper and lower) meets the definition of medical necessity for the diagnosis and evaluation of the following:

Other

Lower Extremity

In addition to the above indications, the following indications for lower extremity CT meet the definition of medical necessity for the diagnosis and evaluation of the following:

BILLING/CODING INFORMATION:

The following codes may be used to describe computed tomography of the extremity (upper and lower).

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 (7320073202 and 7370073702, 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 (7320073202 and 7370073702, 76380) within a 12-month period. Computed tomography (7320073202 and 7370073702, 76380) for an oncologic condition in excess of four (4) computed tomography (7320073202 and 7370073702, 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.

Neoplasm: any new and abnormal growth; specifically a new growth of tissue in which the growth is uncontrolled and progressive.

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

Osteoarthropathy: any disease of the joints and bones.

Osteochondritis dissecans (OCD): osteochondritis resulting in the splitting of pieces of cartilage into the joint, particularly the knee joint or shoulder joint. A term for osteochondral fracture.

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.

Osteonecrosis: necrosis of bone due to obstruction of its blood supply (avascular, ischemic necrosis or the bone).

Scleroderma (localized): scleroderma confined to the skin and subcutaneous tissue or secondarily involving the musculoskeletal system.

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 Appropriateness Criteria: Acute Shoulder Pain, 2010.
  3. American College of Radiology Appropriateness Criteria: Acute Trauma to the Foot, 2010.
  4. American College of Radiology Appropriateness Criteria: Acute Trauma to the Knee, 2011.
  5. American College of Radiology Appropriateness Criteria: Avascular Necrosis (Osteonecrosis) of the Hip, 2009.
  6. American College of Radiology Appropriateness Criteria: Chronic Ankle Pain, 2012.
  7. American College of Radiology Appropriateness Criteria: Chronic Elbow Pain, 2011.
  8. American College of Radiology Appropriateness Criteria: Chronic Hip Pain, 2011.
  9. American College of Radiology Appropriateness Criteria: Chronic Wrist Pain, 2012.
  10. American College of Radiology Appropriateness Criteria: Imaging After Knee Arthroplasty, 2011.
  11. American College of Radiology Appropriateness Criteria: Primary Bone Tumors, 2013.
  12. American College of Radiology Appropriateness Criteria: Soft-Tissues Masses, 2012.
  13. Buckwalter KA, Rydberg J, Kopecky KK et al. Musculoskeletal imaging with multislice CT. American Journal of Roentgenology 2001; 176: 979-986.
  14. Centers for Medicare & Medicaid Services NCD for Computed Tomography (220.1), 03/12/08.
  15. 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.
  16. 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.
  17. National Cancer Institute-Radiation risks and pediatric computed tomography (CT): A guide for health care providers, 12/12/08.
  18. National Imaging Associates, Inc. Clinical Guidelines-Upper Extremity CT (Hand, Wrist, Elbow, Long Bone or Shoulder) and Lower Extremity CT (Ankle, Foot, Hip or Knee) 08/13.
  19. 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 12/04/14.

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.

Date Printed: August 21, 2017: 07:42 PM