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Group Health Incorporated |
Contractor Name
Group Health, Inc.(NY)
Contractor Number
14330
Contractor Type
Carrier
LCD Database ID Number
DL19596
LCD Title
Measurement of Post-Void Residual Urine and/or Bladder Capacity by Ultrasound
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2005 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
· 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 1862 (a)(1)(A)
This section allows coverage and payment for only those services considered medically reasonable and necessary.
· Title XVIII of the Social Security Act, Section 1833 (e)
This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
· CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 70 and Chapter 13, Sections 20 and 90
This section addresses payment conditions for radiology services.
· CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 23, Sections 20.9, 20.9.2, 20.9.3, 20.9.4, 20.9.5, and 20.9.6
This section addresses standards of medical surgical practice and the correct coding initiative (CCI).
Primary Geographic Jurisdiction
New York - Queens
Oversight Region
Region II
CMS Consortium
Northeast
Projected Determination Effective Date
07/21/2006
Indications and Limitations of Coverage and/or Medical Necessity
Post-void residual (PVR) urine volume is the volume of urine in the bladder immediately after the completion of voiding. The standard method of determining PVR urine volumes is intermittent catheterization, which is associated with increased risk of urinary infection, urethral trauma and discomfort for the patient. Bladder ultrasound has been introduced as an alternative, noninvasive method, to avoid the potential complications of intermittent catheterization. The use of both ultrasound and catheterization during the same session to determine PVR is not medically necessary.
Bladder ultrasound or bladder scan to determine post-void residual urine employs either a standard ultrasound machine or a portable, battery-powered ultrasound device which consists of a hand-held ultrasound
transducer (scanhead) and a base unit with a display screen. This unit automatically calculates and displays the bladder volume.
Bladder scan ultrasonography is utilized to assess post-void urinary bladder retention. It can be an important component in the diagnosis and ongoing management of lower urinary tract dysfunctions, including, but not limited to, urinary incontinence and/or neurogenic bladder.
When ultrasound measurement for post-void residual is the only service clinically indicated and/or rendered, it is inappropriate to report a pelvic ultrasound code (76856 or 76857) instead of, or in addition to, this service. Likewise, if a pelvic ultrasound code is appropriately billed, it is inappropriate to bill separately for the PVR measurement since payment for this has already been included in the payment of the pelvic study.
Routine ultrasound examination of incontinent patients in nursing homes and skilled nursing facilities is not warranted. PVR determination is only one component of incontinence evaluation. The patient must be capable of participating in the complete evaluation process and in the treatment plan in order for this testing to be appropriate. The use of ultrasound to measure PVR is not medically necessary if no treatment is planned, regardless of the findings.
Coverage Topics
Diagnostic Tests and X-Rays
Type of Bill Code 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.
999x
Not Applicable
Revenue Code 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.
99999
Not Applicable
CPT/HCPCS Codes
51798
MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY ULTRASOUND, NON-IMAGING
ICD-9-CM Codes that Support Medical Necessity
ICD-9-CM code listings may cover a range and include truncated codes. It is the provider's responsibility to avoid truncated codes by selecting a code(s) 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 was performed.
It is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.
Further, these ICD-9-CM can be used only with the conditions listed in the Indications and Limitations section of this LCD.
596.0
BLADDER NECK OBSTRUCTION
596.4
ATONY OF BLADDER
596.54
NEUROGENIC BLADDER NOS
600.01
HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION
600.21
BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION
625.6
STRESS INCONTINENCE FEMALE
788.1
DYSURIA
788.20
RETENTION OF URINE UNSPECIFIED
788.21
INCOMPLETE BLADDER EMPTYING
788.29
OTHER SPECIFIED RETENTION OF URINE
788.30
URINARY INCONTINENCE UNSPECIFIED
788.31
URGE INCONTINENCE
788.32
STRESS INCONTINENCE MALE
788.33
MIXED INCONTINENCE (MALE) (FEMALE)
788.34
INCONTINENCE WITHOUT SENSORY AWARENESS
788.35
POST-VOID DRIBBLING
788.36
NOCTURNAL ENURESIS
788.37
CONTINUOUS LEAKAGE
788.38
OVERFLOW INCONTINENCE
788.39
OTHER URINARY INCONTINENCE
788.41
URINARY FREQUENCY
788.42
POLYURIA
788.43
NOCTURIA
788.5
OLIGURIA AND ANURIA
788.61
SPLITTING OF URINARY STREAM
788.62
SLOWING OF URINARY STREAM
788.63
URGENCY OF URINATION
788.69
OTHER ABNORMALITY OF URINARY STREAM
788.7
URETHRAL DISCHARGE
788.8
EXTRAVASATION OF URINE
788.9
OTHER SYMPTOMS INVOLVING URINARY SYSTEM
Diagnoses that Support Medical Necessity
ICD-9-CM Codes that DO NOT Support Medical Necessity
Diagnoses that DO NOT Support Medical Necessity
Documentation Requirements
1. Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned.
2. The patient's clinical record should indicate the plan of treatment and any changes/alterations in medications prescribed for the treatment of the patient's condition. There must be an attending/treating physician's order for each test documented in the patient's medical/clinical record
3. The medical record should include the results of the test including documentation that the measurement was done immediately post-void, along with the date of the test, and identification of the person performing the test.
4. Documentation justifying the need for this service, at the time the service was rendered must be available to Medicare upon request.
Appendices
Utilization Guidelines
CPT code 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non imaging) should not be performed more than once per day.
Sources of Information and Basis for Decision
1. Urinary Incontinence in Adults. NIH Consensus Statement Online 1988 Oct 3-5 (cited March 2000); 7(5):1-32.
2. Anton, HA, et al. "Clinical Utility of a Portable Ultrasound Device in Intermittent Catheterization." Archives of Physical Medicine and Rehabilitation, 1998; 79: 172-175.
3. Coombes, GM, Millard, RJ "The Accuracy of Portable Ultrasound Scanning in the Measurement of Residual Urine Volume." The Journal of Urology, December 1994; 152: 2083-2085.
4. Revord, JP, Opitz, JL, Murtaugh, P, Harrison, J. "Determining Residual Urine Volume Using a Portable Ultrasonographic Device." Archives of Physical Medicine and Rehabilitation, May 1993; 74: 457-462.
5. Stam, HJ, Rijst, HVD, Bangma, BD. "Ultrasonic Determination of Bladder Volume in Patients with Spinal Cord Injury." International Journal of Rehabilitation, 1991; 14: 256-260.
6. Moore, D, Edwards, K. "Using a Portable Bladder Scan to Reduce the Incidence of Nosocomial Urinary Tract Infection." MedSurg Nursing, Vol 6, No. 1: 39-44.
7. New York State Urological Society
8. New Jersey Carrier Advisory Committee
9. Empire Medicare Services New Jersey Medical Director
10. Other Medicare Carries – New York, Pennsylvania, Virginia,
Advisory Committee Meeting Notes
Advisory Committee Meeting Date: 02/08/2006
This LCD does not reflect the sole opinion of the carrier or Carrier Medical Director. Although the final decision rests with the carrier, this LCD was developed in cooperation with the Carrier Advisory Committee, which includes representatives from all the specialty societies in New Jersey and the Medical Society of the State of New York.
Start Date of Comment Period
02/08/2006
End Date of Comment Period
03/24/2006
Start Date of Notice Period
Revision History
#6
- Returned to the CAC 02/08/2006
- Added Documentation Requirement #3
- Added Utilization Guidelines.
#5
01/30/2006
Policy returned to the June 2005 CAC by Empire Medicare Services (NY and NJ) to remove some sections of Indications and Limitations relating to training and accreditation; clarify reporting post void residual vs. pelvic ultrasound; remove ICD codes 595.9, 596.3, 599.0, 599.7, 788.0; add ICD code 596.
LCD revised to coordinate with other NYS Medicare carrier.
#4
10/01/2004
(1) Limitations #1, 2 and 3 were deleted.
(2) Following ICD-9-CM codes were added: 595.0, 596.3, 599.0, 599.7, 600.01, 600.21 and 788.63
(3) In addition, ICD-9-CM code 788.38 was added as a result of the 2005 ICD-9-CM update.
#3
01/01/2004
Policy revised to conform with the mandated CMS policy formatting, CR 3010.
#2
01/01/2003
New CPT-4 code for bladder scan effective for services rendered on and after January 1, 2003. Also, addition of home (12) to payable places of service.
02/01/2001
Policy revised to conform with the mandated CMS policy formatting
#1
11/05/1999
Additions to "Sources of Information" section of the policy
01/29/2005 - CPT/HCPCS code G0050 was deleted from group 1
Date Last Reviewed
03/27/2006