Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302, 12501, 12301, 12201
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27518
LCD Title
Radiologic Examination of the Chest (CXR)
Contractor’s Determination Number
L27518
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 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)(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.
Pub 100-2, Chapter 15, Diagnostic X-rays
Pub 100-2, Chapter 6, Outpatient Hospital Services
Primary Geographic Jurisdiction
Pennsylvania, Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after 08/01/2008
Revision Ending Date
08/31/2008
Indications and Limitations of Coverage 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
Radiologic examination of the chest (chest X-ray) facilitates the detection, diagnosis, staging and management of pathophysiologic processes involving thoracic, cardiovascular, pulmonary and mediastinal structures, contiguous coverings and the bony thorax. Preoperative chest x-rays are covered if the patient is scheduled for surgery with the administration of general anesthesia.
Chest X-rays are utilized for a variety of clinical indications. When repeated testing is medically necessary, the frequency of testing is dependent on multiple factors; e.g., the patient’s condition/diagnosis, acuity, and the procedures/interventions being done.
Most commonly, chest x-rays require no more than two views. Some clinical situations / specific indications may require more; e.g., multiple views to characterize a pleural effusion prior to thoracentesis. Documentation must support the need for more that two views and be made available upon request.
Chest x-rays being performed solely for hospital policy or state law purposes will be denied.
Coverage Topic
Diagnostic Tests, X-rays, and Lab Services
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.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
18x | Hospital-swing beds |
21x | SNF-inpatient, Part A |
22x | SNF-inpatient or home health visits (Part B only) |
23x | SNF-outpatient (HHA-A also) |
28x | SNF-swing beds |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
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.
0324 | Radiology diagnostic-chest X-ray |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
71010 | RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL |
71015 | RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL |
71020 | RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; |
71021 | RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE |
71022 | RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS |
71023 | RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY |
71030 | RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; |
71034 | RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY |
71035 | RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) |
ICD-9 Codes that Support Medical Necessity
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.
003.22 | SALMONELLA PNEUMONIA |
AMEBIC LIVER ABSCESS - AMEBIC LUNG ABSCESS | |
PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - LATE EFFECTS OF OTHER AND UNSPECIFIED INFECTIOUS AND PARASITIC DISEASES | |
MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - NEOPLASM OF UNSPECIFIED NATURE SITE UNSPECIFIED | |
GOITER SPECIFIED AS SIMPLE - UNSPECIFIED DISORDER OF THYROID | |
DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - UNSPECIFIED DISORDER OF PARATHYROID GLAND | |
PERSISTENT HYPERPLASIA OF THYMUS - UNSPECIFIED DISEASE OF THYMUS GLAND | |
GLUCOCORTICOID DEFICIENCY - MINERALOCORTICOID DEFICIENCY | |
CARCINOID SYNDROME - ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED | |
KWASHIORKOR - UNSPECIFIED DISORDER OF IMMUNE MECHANISM | |
IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC) - POLYCYTHEMIA SECONDARY | |
CHRONIC LYMPHADENITIS - LYMPHADENITIS UNSPECIFIED EXCEPT MESENTERIC | |
289.7 | METHEMOGLOBINEMIA |
DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE - UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE | |
294.8 | OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE |
300.11 | CONVERSION DISORDER |
MUSCULOSKELETAL MALFUNCTION ARISING FROM MENTAL FACTORS - CARDIOVASCULAR MALFUNCTION ARISING FROM MENTAL FACTORS | |
310.1 | PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE |
310.9 | UNSPECIFIED NONPSYCHOTIC MENTAL DISORDER FOLLOWING ORGANIC BRAIN DAMAGE |
HEMOPHILUS MENINGITIS - INTRACRANIAL AND INTRASPINAL ABSCESS OF UNSPECIFIED SITE | |
326 | LATE EFFECTS OF INTRACRANIAL ABSCESS OR PYOGENIC INFECTION |
ORGANIC SLEEP APNEA, UNSPECIFIED - OTHER ORGANIC SLEEP APNEA | |
ALZHEIMER'S DISEASE - CEREBRAL DEGENERATION UNSPECIFIED | |
AMYOTROPHIC LATERAL SCLEROSIS - OTHER MOTOR NEURON DISEASES | |
SYRINGOMYELIA AND SYRINGOBULBIA - UNSPECIFIED DISEASE OF SPINAL CORD | |
337.9 | UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM |
CENTRAL PAIN SYNDROME - CHRONIC PAIN SYNDROME | |
MULTIPLE SCLEROSIS - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE | |
QUADRIPLEGIA UNSPECIFIED - EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY | |
CEREBRAL CYSTS - UNSPECIFIED DISORDERS OF NERVOUS SYSTEM | |
BRACHIAL PLEXUS LESIONS - MONONEURITIS OF UPPER LIMB UNSPECIFIED | |
355.9 | MONONEURITIS OF UNSPECIFIED SITE |
HEREDITARY PERIPHERAL NEUROPATHY - MYOPATHY UNSPECIFIED | |
368.2 | DIPLOPIA |
OTHER SPECIFIED VISUAL DISTURBANCES - UNSPECIFIED VISUAL LOSS | |
PTOSIS OF EYELID UNSPECIFIED - BLEPHAROCHALASIS | |
379.90 | DISORDER OF EYE UNSPECIFIED |
RHEUMATIC FEVER WITHOUT HEART INVOLVEMENT - UNSPECIFIED CIRCULATORY SYSTEM DISORDER | |
ACUTE NASOPHARYNGITIS (COMMON COLD) - UNSPECIFIED DISEASE OF RESPIRATORY SYSTEM | |
ACHALASIA AND CARDIOSPASM - UNSPECIFIED INTESTINAL MALABSORPTION | |
ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - OTHER SPECIFIED DISORDERS OF URETHRA | |
SOLITARY CYST OF BREAST - UNSPECIFIED BREAST DISORDER | |
630 | HYDATIDIFORM MOLE |
SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - SPONTANEOUS ABORTION COMPLETE COMPLICATED BY EMBOLISM | |
LEGALLY INDUCED ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - LEGALLY INDUCED ABORTION COMPLETE COMPLICATED BY EMBOLISM | |
ILLEGAL ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - ILLEGAL ABORTION COMPLETE COMPLICATED BY EMBOLISM | |
LEGALLY UNSPECIFIED TYPE OF ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - LEGALLY UNSPECIFIED ABORTION COMPLETE COMPLICATED BY EMBOLISM | |
638.6 | FAILED ATTEMPTED ABORTION COMPLICATED BY EMBOLISM |
GENITAL TRACT AND PELVIC INFECTION FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES - UNSPECIFIED COMPLICATION FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES | |
BENIGN ESSENTIAL HYPERTENSION COMPLICATING PREGNANCY CHILDBIRTH AND THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED POSTPARTUM HYPERTENSION | |
DIABETES MELLITUS OF MOTHER COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER CURRENT CONDITIONS CLASSIFIABLE ELSEWHERE OF MOTHER POSTPARTUM | |
PULMONARY COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED COMPLICATION OF LABOR AND DELIVERY POSTPARTUM CONDITION OR COMPLICATION | |
DEEP PHLEBOTHROMBOSIS ANTEPARTUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER OBSTETRICAL PULMONARY EMBOLISM POSTPARTUM | |
PERIPART CARDIOMYOPATHY UNSPECIFIED - PERIPARTUM CARDIOMYOPATHY WITH POSTPARTUM CONDITION OR COMPLICATION | |
GALACTORRHEA ASSOCIATED WITH CHILDBIRTH UNSPECIFIED AS TO EPISODE OF CARE - GALACTORRHEA POSTPARTUM CONDITION OR COMPLICATION | |
682.2 | CELLULITIS AND ABSCESS OF TRUNK |
683 | ACUTE LYMPHADENITIS |
DERMATITIS HERPETIFORMIS - PSORIATIC ARTHROPATHY | |
701.0 | CIRCUMSCRIBED SCLERODERMA |
SYSTEMIC LUPUS ERYTHEMATOSUS - UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES | |
PALINDROMIC RHEUMATISM SITE UNSPECIFIED - UNSPECIFIED INFLAMMATORY SPONDYLOPATHY | |
SPINAL STENOSIS IN CERVICAL REGION - POLYMYALGIA RHEUMATICA | |
728.2 | MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED |
RHEUMATISM UNSPECIFIED AND FIBROSITIS - UNSPECIFIED INFECTION OF BONE IN MULTIPLE SITES | |
731.2 | HYPERTROPHIC PULMONARY OSTEOARTHROPATHY |
PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE | |
733.6 | TIETZE'S DISEASE |
733.95 | STRESS FRACTURE OF OTHER BONE |
ADOLESCENT POSTURAL KYPHOSIS - ACQUIRED MUSCULOSKELETAL DEFORMITY OF UNSPECIFIED SITE | |
739.2 | NONALLOPATHIC LESIONS OF THORACIC REGION NOT ELSEWHERE CLASSIFIED |
739.8 | NONALLOPATHIC LESIONS OF RIB CAGE NOT ELSEWHERE CLASSIFIED |
ANENCEPHALUS - CONGENITAL ANOMALY UNSPECIFIED | |
760.3 | OTHER CHRONIC MATERNAL CIRCULATORY AND RESPIRATORY DISEASES AFFECTING FETUS OR NEWBORN |
FETAL DISTRESS BEFORE ONSET OF LABOR IN LIVEBORN INFANT - MILD OR MODERATE BIRTH ASPHYXIA | |
768.9 | UNSPECIFIED SEVERITY OF BIRTH ASPHYXIA IN LIVEBORN INFANT |
769 | RESPIRATORY DISTRESS SYNDROME IN NEWBORN |
FETAL AND NEWBORN ASPIRATION, UNSPECIFIED - UNSPECIFIED RESPIRATORY CONDITION OF FETUS AND NEWBORN | |
773.3 | HYDROPS FETALIS DUE TO ISOIMMUNIZATION |
SYNDROME OF 'INFANT OF A DIABETIC MOTHER' - UNSPECIFIED ENDOCRINE AND METABOLIC DISTURBANCES SPECIFIC TO THE FETUS AND NEWBORN | |
776.2 | DISSEMINATED INTRAVASCULAR COAGULATION IN NEWBORN |
HYDROPS FETALIS NOT DUE TO ISOIMMUNIZATION - UNSPECIFIED CONDITION ORIGINATING IN THE PERINATAL PERIOD | |
COMA - OTHER UNKNOWN AND UNSPECIFIED CAUSE OF MORBIDITY OR MORTALITY | |
CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY | |
CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY | |
CLOSED FRACTURE OF RIB(S) UNSPECIFIED - OPEN FRACTURE OF LARYNX AND TRACHEA | |
FRACTURE OF BONES OF TRUNK CLOSED - FRACTURE OF BONES OF TRUNK OPEN | |
MULTIPLE FRACTURES INVOLVING BOTH LOWER LIMBS LOWER WITH UPPER LIMB AND LOWER LIMB(S) WITH RIB(S) AND STERNUM CLOSED - MULTIPLE FRACTURES INVOLVING BOTH LOWER LIMBS LOWER WITH UPPER LIMB AND LOWER LIMB(S) WITH RIB(S) AND STERNUM OPEN | |
CLOSED DISLOCATION CERVICAL VERTEBRA UNSPECIFIED - OPEN DISLOCATION OTHER LOCATION | |
NECK SPRAIN - SPRAIN OF UNSPECIFIED SITE OF BACK | |
SPRAIN OF RIBS - OTHER SPRAIN OF STERNUM | |
CONCUSSION WITH NO LOSS OF CONSCIOUSNESS - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED | |
TRAUMATIC PNEUMOTHORAX WITHOUT OPEN WOUND INTO THORAX - INTERNAL INJURY TO UNSPECIFIED OR ILL-DEFINED ORGANS WITH OPEN WOUND INTO CAVITY | |
OPEN WOUND OF LARYNX WITH TRACHEA UNCOMPLICATED - OPEN WOUND OF BACK COMPLICATED | |
OPEN WOUND OF BREAST WITHOUT COMPLICATION - OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) COMPLICATED | |
INJURY TO CAROTID ARTERY UNSPECIFIED - LATE EFFECT OF OTHER AND UNSPECIFIED EXTERNAL CAUSES | |
CONTUSION OF BREAST - CONTUSION OF UNSPECIFIED PART OF TRUNK | |
926.11 | CRUSHING INJURY OF BACK |
926.19 | CRUSHING INJURY OF OTHER SPECIFIED SITES OF TRUNK |
926.8 | CRUSHING INJURY OF MULTIPLE SITES OF TRUNK |
926.9 | CRUSHING INJURY OF UNSPECIFIED SITE OF TRUNK |
CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF MULTIPLE SITES OF UPPER ARM | |
FOREIGN BODY IN NOSE - FOREIGN BODY IN DIGESTIVE SYSTEM UNSPECIFIED | |
CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART | |
AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA - OTHER AND UNSPECIFIED COMPLICATIONS OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED | |
CONTACT WITH OR EXPOSURE TO CHOLERA - CARRIER OR SUSPECTED CARRIER OF OTHER SPECIFIED INFECTIOUS ORGANISM | |
INFECTION WITH MICROORGANISMS RESISTANT TO PENICILLINS - UNSPECIFIED PERSONAL HISTORY OF MALIGNANT NEOPLASM | |
PERSONAL HISTORY OF UNSPECIFIED INFECTIOUS AND PARASITIC DISEASE - PERSONAL HISTORY OF TUBERCULOSIS | |
V12.03 | PERSONAL HISTORY OF MALARIA |
V12.09 | PERSONAL HISTORY OF OTHER SPECIFIED INFECTIOUS AND PARASITIC DISEASE |
PERSONAL HISTORY, UNSPECIFIED DISEASE OF RESPIRATORY SYSTEM - PERSONAL HISTORY, OTHER DISEASES OF RESPIRATORY SYSTEM | |
V15.1 | PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH |
V15.7 | PERSONAL HISTORY OF CONTRACEPTION PRESENTING HAZARDS TO HEALTH |
V15.82 | PERSONAL HISTORY OF TOBACCO USE |
V15.84 | PERSONAL HISTORY OF EXPOSURE TO ASBESTOS |
V41.6 | PROBLEMS WITH SWALLOWING AND MASTICATION |
HEART REPLACED BY TRANSPLANT - HEART VALVE REPLACED BY TRANSPLANT | |
V42.6 | LUNG REPLACED BY TRANSPLANT |
HEART REPLACED BY HEART ASSIST DEVICE - HEART VALVE REPLACED BY OTHER MEANS | |
V43.81 | LARYNX REPLACEMENT STATUS |
UNSPECIFIED CARDIAC DEVICE IN SITU - OTHER SPECIFIED CARDIAC DEVICE IN SITU | |
V45.2 | POSTSURGICAL PRESENCE OF CEREBROSPINAL FLUID DRAINAGE DEVICE |
V45.81 | POSTSURGICAL AORTOCORONARY BYPASS STATUS |
V45.89 | OTHER POSTSURGICAL STATUS |
DEPENDENCE ON RESPIRATOR, STATUS - ENCOUNTER FOR RESPIRATOR DEPENDENCE DURING POWER FAILURE | |
DEFICIENCIES OF INTERNAL ORGANS - OTHER CARDIORESPIRATORY PROBLEMS | |
V55.0 | ATTENTION TO TRACHEOSTOMY |
ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY - ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION | |
V58.49 | OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY |
LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS - LONG-TERM (CURRENT) USE OF STEROIDS | |
V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
V58.74 | AFTERCARE FOLLOWING SURGERY OF THE RESPIRATORY SYSTEM NOT ELSEWHERE CLASSIFIED |
FITTING AND ADJUSTMENT OF VASCULAR CATHETER - OTHER SPECIFIED AFTERCARE | |
LAPAROSCOPIC SURGICAL PROCEDURE CONVERTED TO OPEN PROCEDURE - ARTHROSCOPIC SURGICAL PROCEDURE CONVERTED TO OPEN PROCEDURE | |
FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY - FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY | |
FOLLOW-UP EXAMINATION FOLLOWING RADIOTHERAPY - FOLLOW-UP EXAMINATION FOLLOWING CHEMOTHERAPY | |
V67.4 | FOLLOWING TREATMENT OF HEALED FRACTURE |
FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED - OTHER FOLLOW-UP EXAMINATION | |
OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM - OBSERVATION FOR SUSPECTED TUBERCULOSIS | |
V71.7 | OBSERVATION FOR SUSPECTED CARDIOVASCULAR DISEASE |
OBSERVATION AND EVALUATION FOR SUSPECTED EXPOSURE TO ANTHRAX - OBSERVATION AND EVALUATION FOR SUSPECTED EXPOSURE TO OTHER BIOLOGICAL AGENT | |
PRE-OPERATIVE CARDIOVASCULAR EXAMINATION - PRE-OPERATIVE EXAMINATION UNSPECIFIED | |
V74.1 | SCREENING EXAMINATION FOR PULMONARY TUBERCULOSIS |
V76.0 | SPECIAL SCREENING FOR MALIGNANT NEOPLASMS OF THE RESPIRATORY ORGANS |
BREAST SCREENING UNSPECIFIED - OTHER SCREENING MAMMOGRAM | |
V76.3 | SCREENING FOR MALIGNANT NEOPLASMS OF THE BLADDER |
V83.81 | CYSTIC FIBROSIS GENE CARRIER |
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
Screening tests in the absence of signs, symptoms or complaints may be denied under section 1862(a)(7) of the Social Security Act.
ROUTINE GENERAL MEDICAL EXAMINATION AT A HEALTH CARE FACILITY - UNSPECIFIED GENERAL MEDICAL EXAMINATION | |
V72.5 | RADIOLOGICAL EXAMINATION NOT ELSEWHERE CLASSIFIED |
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- 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.
- 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.
- There must be a physician order(s) for the x-ray(s).
- For a four-view chest x-ray, documentation as to the medical necessity of the four views is expected.
- The medical record documentation is expected to indicate the medical necessity of the test, including the frequency of repeated testing. In addition, documentation that the service was performed, including the test results, should be in the patient’s medical records (i.e., copy of radiology test performed with physician interpretation of the results). This information is usually found in the office/progress notes, hospital notes, and/or laboratory results.
- If the provider of the service is other than the ordering/referring physician that provider is expected to maintain hard copy documentation of the results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in his/her order for the test.
- Documentation is expected to show that the services met criteria and are not excluded from coverage.
- Failure to respond to a request for documentation will result in denial.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.
Screening tests in the absence of signs, symptoms or complaints may be denied under section 1862(a)(7) of the Social Security Act.
Chest x-rays being performed solely for hospital policy or state law purposes may be denied.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27518
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
08/01/2008 |
L27518 |
LCD effective 08/01/2008 for DC Part A, Maryland Part A, and Pennsylvania Part A. LCD is now effective for DC Part A and DCMA Part B; Maryland Part A and Maryland Part B; Pennsylvania Part A; and Delaware Part B. |
05/23/2008 |
L27518 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D39 |
Original LCD posted for comment. |
Last Reviewed On
07/31/2008
Related Documents
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