Local Coverage Determination (LCD): Non-Vascular Extremity Ultrasound (L34716)

Local Coverage Determination (LCD): Non-Vascular Extremity Ultrasound (L34716) Contractor Information Contractor Name Novitas Solutions, Inc. LCD Information Document Information LCD ID L34716 LCD Title Non-Vascular Extremity Ultrasound AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2013 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Original Effective Date For services performed on or after 07/24/2014 Revision Effective Date For services performed on or after 07/24/2014 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 06/05/2014 Notice Period End Date 07/23/2014

CMS National Coverage Policy Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury. Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim. CMS Internet-Only Manual (IOM) Publication 100-03, Chapter 1, Section 220. 5, Ultrasound Diagnostic Procedures CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 7, Section 50, Billing Part B Radiology Services and Other Diagnostic Procedures CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 70, Payment Conditions for Radiology Services CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 13, Section 10.1, Billing Part B Radiology Services and Other Diagnostic Procedures CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 16, Section 40.2, Payment Limit for Purchased Services Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits. Ultrasound of the extremity is a non-invasive imaging technique that uses high-frequency sound waves to evaluate the extremities (arms and legs including shoulders, hips, hands and feet), providing real-time, two-dimensional images. Longitudinal, transverse and oblique images of the area of interest are obtained. Musculoskeletal Ultrasound (MSK US) is highly operator dependent, making proper equipment and technique critical to obtaining an accurate examination. Basic knowledge of ultrasound physics and proper use of the controls are needed to produce adequate images. Ultrasound, echography and sonography are all terms that may be used interchangeably to describe this particular imaging technique. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services. Per CPT guidelines, "A complete ultrasound examination of an extremity (76881) consists of real time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality."

Medical record documentation must support the need for a complete examination and must include a report of the study findings that indicates all of the above structures were examined and the findings for each. According to CPT guidelines, Code 76882 refers to an examination of an extremity that would be performed primarily for evaluation of muscles, tendons, joints, and/or soft tissues. This is a limited examination of the extremity where a specific anatomic structure such as a tendon or muscle is assessed. In addition, the code would be used to evaluate a soft-tissue mass that may be present in an extremity where knowledge of its cystic or solid characteristics is needed. Indications: Extremity ultrasound examination (complete and limited) may be medically reasonable and necessary for the following conditions: 1. To detect cysts, abscesses and effusions; 2. To distinguish solid tumors from fluid-filled cysts; 3. To evaluate tendons (including tears, especially those that are partial, tendonitis and tenosynovitis), joints, ligaments, soft tissue masses, nerve compression and stress fractures. Evaluation of ganglion cysts, plantar fascia and neuroma may be medically necessary under certain circumstances. Refer to the Limitations section below for additional information. 4. To aid in the diagnosis of and surgical removal of foreign bodies. Limitations: 1. Extremity ultrasound must be performed by individuals who possess the knowledge and skill required for the proper performance of this test. This includes, but is not limited to, physicians, NPs, PAs and/or qualified technicians (sonographers). Sonographers, NPs or PAs must be under the general supervision of a physician. Documentation of training and/or qualifications must be kept on file and be made available to the Contractor upon request. 2. Extremity ultrasound (CPT codes 76881 and 76882) is limited to studies of the arms and legs. The upper extremity includes any part of the arm from the shoulder joint through the fingers including the clavicular and the scapular portions of the upper appendage but excluding the sternoclavicular joint. The lower extremity includes any part of the leg inferior to or below the inguinal ligament. 3. Extremity ultrasound is considered not medically necessary for the following conditions: o plantar warts; o neuromas (where the clinical impression is obvious and ultrasound is not likely to add further information); o bunions; o paronychia; o visible and/or palpable superficial abscesses

4. Bilateral studies are allowed only if there is pathology of both extremities dictating medical necessity for two distinct examinations. It is not reasonable and necessary to perform the contralateral extremity as a "control." 5. Extremity ultrasound is not considered medically necessary for neuromas, plantar fasciitis, superficial ganglia, and superficial abscesses unless there is documented evidence of some clinical presentation that obscures the clinician's ability to establish these simple clinical diagnoses. 6. In the case of plantar fasciitis unrelated to spondyloarthropathy, diagnostic ultrasound is NOT to be used in making an initial determination (diagnosis) and then should ONLY be used after a failed course of conservative management. Even at that time, it is to be used only once. 7. Lesions of the plantar nerve and plantar fascia (when reported without 720.0 or 720.89), may be considered on appeal with submission of the appropriate supporting documentation. 8. Non-vascular ultrasound is considered not reasonable and necessary for the following: avascular necrosis, chondromalacia patella, cruciate ligament disorder, shoulder dislocation, Hoffa s fat pad, labrum disorders of the hip or shoulder, intra articular loose bodies, marrow disorders, meniscal disorders, osteochondritis dessicans/osteochondral defect, os trigonum syndrome, osteomyelitis, plantar plate injuries, sesamoid complex disorders, spurs, (including those of the shoulder) or tumors. It is not expected that there will be routine cascading of tests from ultrasound to MRI and vice versa when imaging of extremities is medically necessary. Other Comments: Physicians who perform and/or interpret diagnostic musculoskeletal (MSK) ultrasound (US) examinations must be licensed medical practitioners who have a thorough understanding of the indications and guidelines for MSK US examinations as well as a familiarity with the basic physical principles and limitations of the technology of US imaging. They must be familiar with the best method of imaging for extremity abnormalities. They must have an understanding of US technology and instrumentation, US power output, equipment calibration, and safety. Physicians responsible for diagnostic MSK US examinations must be able to demonstrate familiarity with the anatomy, physiology, and pathophysiology of the anatomic areas that are being examined. These physicians must provide evidence of the training and competence needed to perform and/or interpret diagnostic MSK US examinations successfully, upon request. The training should also include methods of documentation and reporting of US studies. The diagnostic medical sonographer must be qualified, by appropriate training, to perform diagnostic US. This qualification can be demonstrated by certification for same by a nationally recognized certifying body. As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and

necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: Safe and effective. Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member. o Furnished in a setting appropriate to the patient's medical needs and condition. o Ordered and furnished by qualified personnel. o o One that meets, but does not exceed, the patient's medical needs. At least as beneficial as an existing and available medically appropriate alternative. Coding Information 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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 071x Clinic - Rural Health 073x Clinic - Freestanding 083x Ambulatory Surgery Center 085x Critical Access Hospital 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 policy 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 policy should be assumed to apply equally to all Revenue Codes. Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04 Claims Processing Manual for further guidance. 0402 Other Imaging Services - Ultrasound 0972 Professional Fees - Radiology - Diagnostic CPT/HCPCS Codes Group 1 Paragraph: Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. Group 1 Codes: 76881 Us xtr non-vasc complete 76882 Us xtr non-vasc lmtd ICD-9 Codes that Support Medical Necessity Group 1 Paragraph: It is the provider s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. The following support the medical necessity of procedure codes 76881 and 76882: Group 1 Codes: 215.2 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER 215.3 OTHER BENIGN NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP 229.8 BENIGN NEOPLASM OF OTHER SPECIFIED SITES 238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE 238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES 239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN 274.00 GOUTY ARTHROPATHY, UNSPECIFIED 274.01 ACUTE GOUTY ARTHROPATHY

274.02 CHRONIC GOUTY ARTHROPATHY WITHOUT MENTION OF TOPHUS (TOPHI) 274.03 CHRONIC GOUTY ARTHROPATHY WITH TOPHUS (TOPHI) 354.0 CARPAL TUNNEL SYNDROME 354.2 LESION OF ULNAR NERVE 355.1 MERALGIA PARESTHETICA 355.3 LESION OF LATERAL POPLITEAL NERVE 355.4 LESION OF MEDIAL POPLITEAL NERVE 355.5 TARSAL TUNNEL SYNDROME 682.3 CELLULITIS AND ABSCESS OF UPPER ARM AND FOREARM 682.4 CELLULITIS AND ABSCESS OF HAND EXCEPT FINGERS AND THUMB 682.6-682.7 CELLULITIS AND ABSCESS OF LEG EXCEPT FOOT - CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES 682.8 CELLULITIS AND ABSCESS OF OTHER SPECIFIED SITES 682.9 CELLULITIS AND ABSCESS OF UNSPECIFIED SITES 696.0 PSORIATIC ARTHROPATHY CHONDROCALCINOSIS DUE TO DICALCIUM PHOSPHATE CRYSTALS 712.11 - INVOLVING SHOULDER REGION - CHONDROCALCINOSIS DUE TO 712.17 DICALCIUM PHOSPHATE CRYSTALS INVOLVING ANKLE AND FOOT 712.19 CHONDROCALCINOSIS DUE TO DICALCIUM PHOSPHATE CRYSTALS INVOLVING MULTIPLE SITES 712.20 CHONDROCALCINOSIS DUE TO PYROPHOSPHATE CRYSTALS INVOLVING UNSPECIFIED SITE 712.21-712.27 CHONDROCALCINOSIS DUE TO PYROPHOSPHATE CRYSTALS INVOLVING SHOULDER REGION - CHONDROCALCINOSIS DUE TO PYROPHOSPHATE CRYSTALS INVOLVING ANKLE AND FOOT 714.0 RHEUMATOID ARTHRITIS 715.10-715.18 715.90-715.93 715.95-715.98 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING FOREARM OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING PELVIC REGION AND THIGH - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES 717.6 LOOSE BODY IN KNEE 719.01 - EFFUSION OF JOINT OF SHOULDER REGION - EFFUSION OF ANKLE AND 719.07 FOOT JOINT 719.11 - HERARTHROSIS INVOLVING SHOULDER REGION - HEMARTHROSIS 719.17 INVOLVING ANKLE AND FOOT 719.19 HEMARTHROSIS INVOLVING MULTIPLE SITES

719.40 - PAIN IN JOINT SITE UNSPECIFIED - PAIN IN JOINT INVOLVING MULTIPLE 719.49 SITES 719.61 - OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION - OTHER 719.67 SYMPTOMS REFERABLE TO ANKLE AND FOOT JOINT 720.0 ANKYLOSING SPONDYLITIS 720.89 OTHER INFLAMMATORY SPONDYLOPATHIES DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION 726.10 - UNSPECIFIED - OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS 726.19 IN SHOULDER REGION 726.31 - MEDIAL EPICONDYLITIS - OTHER ENTHESOPATHY OF ELBOW REGION 726.39 726.4 ENTHESOPATHY OF WRIST AND CARPUS 726.5 ENTHESOPATHY OF HIP REGION 726.60 - ENTHESOPATHY OF KNEE UNSPECIFIED - OTHER ENTHESOPATHY OF 726.69 KNEE 726.71 ACHILLES BURSITIS OR TENDINITIS 726.72 TIBIALIS TENDINITIS 726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS 726.90 ENTHESOPATHY OF UNSPECIFIED SITE 727.00 - SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED - OTHER SYNOVITIS AND 727.09 TENOSYNOVITIS 727.3 OTHER BURSITIS DISORDERS 727.40 - SYNOVIAL CYST UNSPECIFIED - GANGLION OF TENDON SHEATH 727.42 727.49 OTHER GANGLION AND CYST OF SYNOVIUM TENDON AND BURSA 727.51 SYNOVIAL CYST OF POPLITEAL SPACE 727.59 OTHER RUPTURE OF SYNOVIUM 727.61 - COMPLETE RUPTURE OF ROTATOR CUFF - NONTRAUMATIC RUPTURE OF 727.69 OTHER TENDON 728.82 FOREIGN BODY GRANULOMA OF MUSCLE 728.86 NECROTIZING FASCIITIS 728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA 729.31 HYPERTROPHY OF FAT PAD KNEE 729.5 PAIN IN LIMB 729.6 RESIDUAL FOREIGN BODY IN SOFT TISSUE 729.81 SWELLING OF LIMB 729.90 - DISORDERS OF SOFT TISSUE, UNSPECIFIED - OTHER DISORDERS OF SOFT 729.99 TISSUE 733.94 STRESS FRACTURE OF THE METATARSALS 733.95 STRESS FRACTURE OF OTHER BONE 782.2 LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP 821.01 FRACTURE OF SHAFT OF FEMUR CLOSED 835.00 CLOSED DISLOCATION OF HIP UNSPECIFIED SITE

840.3 INFRASPINATUS (MUSCLE) (TENDON) SPRAIN 840.4 ROTATOR CUFF (CAPSULE) SPRAIN 840.6 SUPRASPINATUS (MUSCLE) (TENDON) SPRAIN 840.8 SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM 840.9 SPRAIN OF UNSPECIFIED SITE OF SHOULDER AND UPPER ARM 841.0 RADIAL COLLATERAL LIGAMENT SPRAIN 841.1 ULNAR COLLATERAL LIGAMENT SPRAIN 841.8 SPRAIN OF OTHER SPECIFIED SITES OF ELBOW AND FOREARM 841.9 SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM 842.00 - SPRAIN OF UNSPECIFIED SITE OF WRIST - OTHER WRIST SPRAIN 842.09 842.10 - SPRAIN OF UNSPECIFIED SITE OF HAND - OTHER HAND SPRAIN 842.19 843.8 SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH 843.9 SPRAIN OF UNSPECIFIED SITE OF HIP AND THIGH 844.0 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE 844.1 SPRAIN OF MEDIAL COLLATERAL LIGAMENT OF KNEE 844.3 SPRAIN OF TIBIOFIBULAR (JOINT) (LIGAMENT) SUPERIOR OF KNEE 844.8 SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG 844.9 SPRAIN OF UNSPECIFIED SITE OF KNEE AND LEG 845.00 - UNSPECIFIED SITE OF ANKLE SPRAIN - OTHER ANKLE SPRAIN 845.09 845.10 - UNSPECIFIED SITE OF FOOT SPRAIN - OTHER FOOT SPRAIN 845.19 923.03 CONTUSION OF UPPER ARM 923.10 - CONTUSION OF FOREARM - CONTUSION OF ELBOW 923.11 923.21 CONTUSION OF WRIST 923.8 CONTUSION OF MULTIPLE SITES OF UPPER LIMB 924.00 - CONTUSION OF THIGH - CONTUSION OF HIP 924.01 924.10 - CONTUSION OF LOWER LEG - CONTUSION OF KNEE 924.11 924.21 CONTUSION OF ANKLE 924.4-924.9 CONTUSION OF MULTIPLE SITES OF LOWER LIMB - CONTUSION OF UNSPECIFIED SITE 959.2-959.3 OTHER AND UNSPECIFIED INJURY TO SHOULDER AND UPPER ARM - OTHER AND UNSPECIFIED INJURY TO ELBOW FOREARM AND WRIST 959.6 OTHER AND UNSPECIFIED INJURY TO HIP AND THIGH 959.7 OTHER AND UNSPECIFIED INJURY TO KNEE LEG ANKLE AND FOOT INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT 996.66 - PROSTHESIS - INFECTION AND INFLAMMATORY REACTION DUE TO 996.67 OTHER INTERNAL ORTHOPEDIC DEVICE IMPLANT AND GRAFT

997.62 INFECTION (CHRONIC) OF AMPUTATION STUMP 998.12 HEMATOMA COMPLICATING A PROCEDURE 998.13 SEROMA COMPLICATING A PROCEDURE ICD-9 Codes that DO NOT Support Medical Necessity Paragraph: All those not listed under the "ICD-9 Codes that Support Medical Necessity" section of this policy. Codes: XX000 Not Applicable General Information Associated Information Documentation Requirements 1. All documentation must be maintained in the patient's medical record and available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient. 3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed. 4. Documentation must support the RT, LT or digit modifiers, as reported. 5. The medical necessity for the study must be documented in the patient's medical record including a permanent record of the ultrasound and its interpretation. The ultrasound report must include all of the following: o Images of all appropriate areas, labeled with exam date, patient identification, and image orientation; and o documentation of the variations from normal, accompanied by measurements; and o formal interpretation. Results of all testing must be shared with the referring physician. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

More than one complete ultrasound per joint, per extremity, in a 12 month period will be considered not medically necessary. Following diagnosis, repetitive studies on the same extremity should be coupled with evidence of the need for a treatment decision. More than four extremity ultrasounds total in a 12 month period, complete or limited, will be considered not medically necessary. Notice: This LCD imposes utilization guideline limitations. Despite Medicare allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. Sources of Information and Basis for Decision L30271, Non-Vascular Extremity Ultrasound, Novitas Solutions Jurisdiction L Local Coverage Determination Other Contractor Policies Contractor Medical Directors Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 07/24/2014 R2 07/24/2014 R1 Revision History Number Revision History Explanation LCD revised to include ICD-9 diagnosis codes that were inadvertently eliminated in the Posted for Notice LCD that was posted on 06/05/2014. LCD posted for notice on 06/05/2014 to become effective 07/24/2014. Please note that through the creation of a uniform LCD across Novitas MAC jurisdictions, this LCD has been assigned a new LCD number. The Non-Vascular Extremity Ultrasound LCD currently in effect will be retired when this LCD becomes effective. 01/16/2014 Draft LCD posted for comment Reason(s) for Change Typographical Error Creation of Uniform LCDs With Other MAC Jurisdiction

Associated Documents Attachments N/A Related Local Coverage Documents N/A Related National Coverage Documents N/A Public Version(s) Updated on 07/15/2014 with effective dates 07/24/2014 - N/A Updated on 05/29/2014 with effective dates 07/24/2014 - N/A Updated on 05/29/2014 with effective dates 07/24/2014 - N/A