CT Scans of Thorax and Chest CPT 71250, 71260, 71275 - Fee amount

procedure code and description


71250- Ct thorax w/o dye - average fee payment - $180 - $190

71275 CTA chest (noncoronary)

71260 CT thorax; with contrast (noncardiac)

71550- Mri chest w/o dye - average fee payment- $430-$440

Coverage Indications, Limitations, and/or Medical Necessity

    A computed tomographic (CT) image is a display of the anatomy of a thin slice of the body developed from multiple x-ray absorption measurements made around the body’s periphery. Unlike conventional tomography, where the image of a thin section is created by blurring out the information from unwanted regions, the CT image is constructed mathematically using data arising only from the section of interest. Generating such an image is confined to cross sections of the anatomy that are oriented essentially perpendicular to the axial dimensions of the body. Reconstruction of the final image can be accomplished in any plane. The CT of the thorax extends from the lung apices to the posterior costophrenic sulci and may extend inferiorly to image the adrenal glands.

    CT of the thorax will be considered medically reasonable and necessary based on the American College of Radiology Guidelines under the following circumstances:

    · Evaluation of clinically suspected occult thoracic pathology (ACR)

    · Evaluation of known or suspected thoracic vascular abnormalities (congenital or acquired)

    · Evaluation and follow-up of pulmonary parenchymal and airway disease

    · Assessment of cardiopulmonary failure or insufficiency

    · Detection and determination of nature and extent of cardiovascular abnormalities such as but no tlimited to aneurysm, dissection, embolism, thrombosis, congenital anomalies, post-operative complications and sequelae of atherosclerotic disease

    · For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema, effusion or pneumothorax

    · For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, allergic , collagen-vascular, environmental or other causes

    · For evaluating thoracic sequelae of remote processes including but not limited to pancreatitis, gastrointestinal perforation and other processes

    · For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, radiation therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or mechanical ventilation

    · Evaluation of the patient with symptoms that may be arising from the chest or be referred to the chest including but not limited to cough, hemoptysis, chest pain, abdominal pain and others

    · Evaluation of abnormalities of the lungs, mediastinum, pleura and chest wall initially found on a standard chest radiographs.

    · Evaluation, staging, and follow-up after therapy (e.g., surgery, radiation, and/or chemotherapy) of lung and other primary or secondary (ACR) thoracic malignancies.

    · Evaluation of a patient who sustained trauma to the pleura, chest wall, mediastinum, and lung.

    · Localization of a thoracic mass prior to biopsy.

    · Evaluation of a patient with myasthenia gravis to rule out thymic tumors.

    · CT of the Thorax is indicated for assessing the appropriateness and feasibility of percutaneous procedures such as biopsy and pleural/parenchymal drainage. CT of the thorax is also indicated for following for sequalae of, and response to treatment of these procedures. It is not expected that patients who have recently had CT scans of the thorax that documented treatable abnormalities, would undergo another CT scan of the chest at the time of the procedure. The procedure should be billed using the codes for the biopsy or drainage, with the appropriate code for CT guidance.

    · Evaluation of a patient with signs and symptoms of pulmonary embolism or pulmonary emboli. (Should be performed with a multidetector spiral scanner).

    · Evaluation of a patient with any other condition/symptom when there is support in medical and scientific literature for the effective use of the scan for the condition being evaluated and the scan is reasonable and necessary for the individual patient.

    A CT scan is reasonable and necessary for the individual patient if the use is found to be medically appropriate considering the patient’s symptoms and preliminary diagnosis.

Magnetic Resonance Imaging (MRI) is a useful diagnostic imaging modality that is capable of demonstrating a wide variety of soft tissue lesions with contrast resolution equal or superior to CT scanning. This LCD addresses MRI of the thorax. MRI studies of other sites and Magnetic Resonance Angiography (MRA) are addressed in other specific LCDs.

The following clinical indications apply to the Computerized Axial Tomography (CT) of the thorax:

  • Evaluation of pulmonary, mediastinal, pleural and chest wall infections and their complications.
  • Detection and characterization of mediastinal neoplasms and other processes.
  • Assessment of cardiopulmonary failure or insufficiency.
  • Diagnosis and/or staging of neoplastic and hematologic processes arising in the thorax or with potential involvement of the thorax.
  • Detection and determination of nature and extent of cardiovascular abnormalities such as, but not limited to, aneurysm, dissection, embolism, thrombosis, congenital anomalies, postoperative complications and sequelae of atherosclerotic disease.
  • For assessing and/or guiding drainage of pulmonary or pleural fluid collections such as abscess, empyema, effusion or pneumothorax.
  • For characterizing and follow-up evaluation of interstitial and alveolar lung disease due to idiopathic, allergic, collagen-vascular, environmental or other causes.
  • For evaluating thoracic sequelae of remote processes including but not limited to pancreatitis, gastrointestinal perforation and other processes.
  • For assessing injury, potential injury or thoracic sequelae after trauma, burn, surgery, transplantation, radiation therapy, chemotherapy or invasive procedure such as pacemaker placement, chest tube placement or mechanical ventilation.
  • Evaluation of the patient with symptoms that may be arising from the chest or be referred to the chest, including but not limited to cough, hemoptysis, chest pain, abdominal pain and others.
  • To further characterize a suspected abnormality detected by another imaging test.

In keeping with American College of Radiology (ACR) Practice Guidelines and Technical Standards, CT thorax should be provided by qualified radiology personnel (radiology technicians, diagnostic radiologists). The patient’s condition should be monitored throughout the procedure. As this involves the patient being in a closed environment, claustrophobia or medical problems exacerbated by the enclosure may be exhibited.

Qualified physicians (such as board-certified radiologists) should perform the interpretation of the films.

The computerized tomographic service should be furnished only when clinically appropriate for the patient’s symptoms or complaints. When performed as a screening function, it will not be covered.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.


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, which 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:
    • 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.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

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.
12X, 13X, 71X, 73X, 77X, 83X, 85X

Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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.


CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
71250©
Ct thorax w/o dye - Fee schedule amount - $160.46
71260©
Ct thorax w/dye  Fee schedule amount - $ 224.49
71270©
Ct thorax w/o & w dye -  Fee schedule amount - $
71275©
CT angiography, chest - $293.89
71550©
Mri chest w/o dye - $336.77
71551©
Mri chest w/dye $446.72
71552©
Mri chest w/o & w/dye $551.10

Billing and Coding Guidelines for CPT 71250 and 71260

Allowable group CPT codes - 71250 or 71260 or 71270 or 76380

Chest CT without contrast (CPT® 71250) can be used for the following: 

* Patient has contraindication to contrast o Follow-up of pulmonary nodule(s) 
* High Resolution CT (HRCT) 
* Low-dose chest CT (CPT® 71250 or S8032) may be approved for non-Medicare lung cancer screening if all of the following criteria are met: • Patient has not received a low-dose CT lung screening in less than 12 months; and 
• Patient has NO signs or symptoms suggestive of underlying lung cancer, and 
• Patient is between 55 and 80 years of age; and 
• Patient has at least a 30 pack-year history of cigarette smoking; and 
• Currently smokes or quit less than 15 years ago

When multiple CPT submitted bundling rules applied 100% of the highest RVU, 50% of the second 

This CPT required Authorization for commercial insurance

The below CPT codes are not paid seperately unless modifier applied

75571 and 76380

Chest CT with contrast (CPT 71260) is indicated in a current or past smoker with a change in cough or a new onset cough lasting greater than 4 weeks.

• Patients taking medications known to cause coughing (e.g. ACE inhibitors) should have medication discontinued. If cough persists > 4 weeks, chest CT with contrast (CPT 71260) or without contrast (CPT 71250) is indicated.

• Patients with no history of smoking and clear chest x-ray should undergo the following algorithm.1,2

o A 3 week trial of antihistamine and decongestant treatment should be performed initially.

o If chronic cough persists after treatment of upper airway cough syndrome, asthma should be ruled out with bronchoprovocation challenge (e.g. methacholine challenge, exhaled nitric oxide test) and spirometry should be performed.

o If bronchoprovocation challenge is not available, an empiric trial of corticosteroids should be performed.

o If cough persists, treatment of gastroesophageal reflux disease should be started and referral to a cough specialist is helpful.

o If cough persists, chest CT (either with contrast [CPT 71260] or without contrast [CPT 71250]) can be performed. 



• Chest x-rays should be overread by a radiologist prior to request for advanced imaging.

• Intrathoracic abnormalities found on chest x-ray, fluoroscopy, abdominal CT scan, or other imaging modalities can be further evaluated with chest CT with contrast (CPT 71260).

• Non-contrast chest CT (CPT 71250) can be used for the following:

o Patient has contraindication to contrast

o Follow-up of pulmonary nodule(s)

o High Resolution CT (HRCT)

o Noncontrast CT is specifically requested by pulmonary specialist

o Other circumstances as specified in the guidelines

• Chest CT without and with contrast (CPT 71270) does not add significant diagnostic information above and beyond that provided by chest CT with contrast, unless a question regarding calcification needs to be resolved.


Chest 71275 CTA chest (noncoronary); with contrast including noncontrast images, if performed, and image post- processing


ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 71250, 71260, 71270, 71275, 71550, 71551 and 71552:
Covered for:
006.4
Amebic lung abscess
011.00–011.06
Tuberculosis of lung, infiltrative
011.10–011.16
Tuberculosis of lung, nodular
011.20–011.26
Tuberculosis of lung with cavitation
011.30–011.36
Tuberculosis of bronchus
011.40–011.46
Tuberculous fibrosis of lung
011.50–011.56
Tuberculous bronchiectasis
011.60–011.66
Tuberculous pneumonia (any form)
011.70–011.76
Tuberculous pneumothorax
011.80–011.86
Other specified pulmonary tuberculosis
011.90–011.96
Pulmonary tuberculosis, unspecified
012.00–012.06
Tuberculosis pleurisy
012.10–012.16
Tuberculosis of intrathoracic lymph nodes
012.20–012.26
Isolated tracheal or bronchial tuberculosis
012.30–012.36
Tuberculous laryngitis
012.80–012.86
Other specified respiratory tuberculosis
015.00–015.06
Tuberculosis of bones and joints, vertebral column
018.90
Miliary tuberculosis, unspecified
022.1
Pulmonary anthrax
022.9
Anthrax unspecified
031.0
Diseases due to other mycobacteria, pulmonary
031.8
Other specified mycobacterial diseases
038.0
Streptococcal septicemia
038.10–038.12
Staphylococcal septicemia
038.2–038.3
Septicemia
038.44
Septicemia due to other gram-negative organisms, serratia
038.49
Septicemia due to gram-negative organisms, other
038.8–038.9
Septicemia
039.1
Actinomycotic infections, pulmonary
042
Human Immunodeficiency Virus (HIV) disease
090.49
Juvenile neurosyphilis, other
093.1
Syphilitic aorititis
115.09
Infection by histoplasma capsulatum with other manifestation
117.3–117.5
Other mycoses
135
Sarcoidosis
136.3
Pneumocystosis
137.0
Late effects of respiratory or unspecified tuberculosis
140.0–140.1
Malignant neoplasm of lip
140.3–140.6
Malignant neoplasm of lip
140.8–140.9
Malignant neoplasm of lip
141.0–141.6
Malignant neoplasm of tongue
141.8–141.9
Malignant neoplasm of tongue
142.0–142.2
Malignant neoplasm of major salivary glands
142.8–142.9
Malignant neoplasm of major salivary glands
143.0–143.1
Malignant neoplasm of gum
143.8–143.9
Malignant neoplasm of gum
144.0–144.1
Malignant neoplasm of floor of mouth
144.8–144.9
Malignant neoplasm of floor of mouth
145.0–145.6
Malignant neoplasm of other and unspecified parts of mouth
145.8–145.9
Malignant neoplasm of other and unspecified parts of mouth
146.0–146.9
Malignant neoplasm of oropharynx
147.0–147.3
Malignant neoplasm of nasopharynx
147.8–147.9
Malignant neoplasm of nasopharynx
148.0–148.3
Malignant neoplasm of hypopharynx
148.8–148.9
Malignant neoplasm of hypopharynx
149.0–149.1
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
149.8–149.9
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
150.0–150.5
Malignant neoplasm of esophagus
150.8–150.9
Malignant neoplasm of esophagus
151.0–151.6
Malignant neoplasm of stomach
151.8–151.9
Malignant neoplasm of stomach
152.0–152.3
Malignant neoplasm of small intestine, including duodenum
152.8–152.9
Malignant neoplasm of small intestine, including duodenum
153.0–153.9
Malignant neoplasm of colon
154.0–154.3
Malignant neoplasm of rectum, rectosigmoid junction and anus
154.8
Malignant neoplasm of rectum, rectosigmoid junction and anus, other
155.0–155.2
Malignant neoplasm of liver and intrahepatic bile ducts
156.0–156.2
Malignant neoplasm of gallbladder and extrahepatic bile ducts
156.8–156.9
Malignant neoplasm of gallbladder and extrahepatic bile ducts
157.0–157.4
Malignant neoplasm of pancreas
157.8–157.9
Malignant neoplasm of pancreas
158.0
Malignant neoplasm of retroperitoneum
158.8–158.9
Malignant neoplasm of retroperitoneum and peritoneum
159.0–159.1
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
159.8–159.9
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
160.0–160.5
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
160.8–160.9
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
161.0–161.3
Malignant neoplasm of larynx
161.8–161.9
Malignant neoplasm of larynx
162.0
Malignant neoplasm of trachea
162.2–162.5
Malignant neoplasm of trachea, bronchus and lung
162.8–162.9
Malignant neoplasm of trachea, bronchus and lung
163.0–163.1
Malignant neoplasm of pleura
163.8–163.9
Malignant neoplasm of pleura
164.0–164.3
Malignant neoplasm of thymus, heart and mediastinum
164.8–164.9
Malignant neoplasm of thymus, heart and mediastinum
165.0
Malignant neoplasm of upper respiratory tract, part unspecified
165.8–165.9
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170.2–170.3
Malignant neoplasm of bone and articular cartilage
171.4–171.9
Malignant neoplasm of connective and other soft tissue
172.2–172.9
Malignant melanoma of skin
173.0–173.9
Other malignant neoplasm of skin
174.0–174.6
Malignant neoplasm of female breast
174.8–174.9
Malignant neoplasm of female breast
175.0
Malignant neoplasm of male breast
175.9
Malignant neoplasm of male breast
176.4
Kaposi’s sarcoma
176.8–176.9
Kaposi’s sarcoma
179
Malignant neoplasm of uterus, part unspecified
180.0–180.1
Malignant neoplasm of cervix uteri
180.8–180.9
Malignant neoplasm of cervix uteri
181
Malignant neoplasm of placenta
182.0–182.1
Malignant neoplasm of body of uterus
182.8
Malignant neoplasm of other specified sites of body of uterus
183.0
Malignant neoplasm of ovary
183.2–183.5
Malignant neoplasm of ovary and other uterine adnexa
183.8–183.9
Malignant neoplasm of ovary and other uterine adnexa
184.8–184.9
Malignant neoplasm of other and unspecified female genital organs
185
Malignant neoplasm of prostate
186.0
Malignant neoplasm of undescended testis
186.9
Malignant neoplasm of testis, other and unspecified
187.1–187.9
Malignant neoplasm of penis and other male genital organs
188.8–188.9
Malignant neoplasm of bladder
189.0–189.4
Malignant neoplasm of kidney and other and unspecified urinary organs
189.8–189.9
Malignant neoplasm of kidney and other and unspecified urinary organs
190.0–190.9
Malignant neoplasm of eye
193
Malignant neoplasm of thyroid gland
195.0–195.5
Malignant neoplasm of other and ill-defined sites
195.8
Malignant neoplasm of other specified sites
196.0–196.3
Secondary and unspecified malignant neoplasm of lymph nodes
196.5–196.6
Secondary and unspecified malignant neoplasm of lymph nodes
196.8–196.9
Secondary and unspecified malignant neoplasm of lymph nodes
197.0–197.8
Secondary malignant neoplasm of respiratory and digestive systems
198.0–198.7
Secondary malignant neoplasm of other specified sites
198.81–198.82
Secondary malignant neoplasm of other specified sites
198.89
Secondary malignant neoplasm of other specified sites
199.0–199.2
Malignant neoplasm without specification of site
200.00–200.08
Reticulosarcoma
200.10–200.18
Lymphosarcoma
200.20–200.28
Burkitt’s tumor or lymphoma
200.30–200.38
Marginal zone lymphoma
200.40–200.48
Mantle cell lymphoma
200.50–200.58
Primary central nervous system lymphoma
200.60–200.68
Anaplastic large cell lymphoma
200.70–200.78
Large cell lymphoma
200.80–200.88
Lymphosarcoma and reticulosarcoma, other named variants
201.00–201.08
Hodgkin’s paragranuloma
201.10–201.18
Hodgkin’s granuloma
201.20–201.28
Hodgkin’s sarcoma
201.40–201.48
Hodgkin’s disease, lymphocytic-histiocytic predominance
201.50–201.58
Hodgkin’s disease, nodular sclerosis
201.60–201.68
Hodgkin’s disease, mixed cellularity
201.70–201.78
Hodgkin’s disease, lymphocytic depletion
201.90–201.98
Hodgkin’s disease, unspecified
202.00–202.08
Nodular lymphoma
202.10–202.18
Mycosis fungoides
202.20–202.28
Sezary’s disease
202.30–202.38
Malignant histiocytosis
202.40–202.48
Leukemic reticuloendotheliosis
202.50–202.58
Letterer-Siwe disease
202.60–202.68
Malignant mast cell tumors
202.70–202.78
Peripheral T cell lymphoma
202.80–202.88
Other lymphomas
202.90–202.98
Other and unspecified malignant neoplasms of lymphoid and histocytic tissue
203.00–203.02
Multiple myeloma
203.10–203.12
Plasma cell leukemia
203.80–203.82
Other immunoproliferative neoplasms
204.00–204.02
Acute lymphoid leukemia
204.10–204.12
Chronic lymphoid leukemia
204.20–204.22
Subacute lymphoid leukemia
204.80–204.82
Other lymphoid leukemia
204.90–204.92
Unspecified lymphoid leukemia
205.00–205.02
Acute myeloid leukemia
205.10–205.12
Chronic myeloid leukemia
205.20–205.22
Subacute myeloid leukemia
205.30–205.32
Myeloid sarcoma
205.80–205.82
Other myeloid leukemia
205.90–205.92
Unspecified myeloid leukemia
206.00–206.02
Acute monocytic leukemia
206.10–206.12
Chronic monocytic leukemia
206.20–206.22
Subacute monocytic leukemia
206.80–206.82
Other monocytic leukemia
206.90–206.92
Unspecified monocytic leukemia
207.00–207.02
Acute erythremia and erythroleukemia
207.10–207.12
Chronic erythremia
207.20–207.22
Megakaryocytic leukemia
207.80–207.82
Other specified leukemia
208.00–208.02
Acute leukemia of unspecified cell type
208.10–208.12
Chronic leukemia of unspecified cell type
208.20–208.22
Subacute leukemia of unspecified cell type
208.80–208.82
Other leukemia of unspecified cell type
208.90–208.92
Unspecified leukemia of unspecified cell type
211.0
Benign neoplasm of esophagus
212.2–212.9
Benign neoplasm of respiratory and intrathoracic organs
213.3
Benign neoplasm of ribs, sternum and clavicle
215.4
Benign neoplasm of thorax
226
Benign neoplasm of thyroid glands
227.1
Benign neoplasm of parathyroid gland
227.6
Benign neoplasm of aortic body and other paraganglia
228.1
Lymphangioma any site
229.8
Benign neoplasm of other specified sites
230.1
Carcinoma in situ of esophagus
231.1–231.2
Carcinoma in situ of respiratory system
231.8
Carcinoma in situ of other specified parts of respiratory system
235.7–235.9
Neoplasm of uncertain behavior of digestive and respiratory systems
237.3
Neoplasm of uncertain behavior of paraganglia
237.6
Neoplasm of uncertain behavior of meninges
237.70
Neurofibromatosis unspecified
237.73
Schwannomatosis
237.79
Other neurofibromatosis
238.0–238.6
Neoplasm of uncertain behavior of other and unspecified sites and tissues
238.72–238.75
Neoplasm of uncertain behavior of other and unspecified sites and tissues
239.0–239.3
Neoplasm of unspecified nature
240.0
Goiter, specified as simple
240.9
Goiter, unspecified
241.0–241.1
Non-toxic nodular goiter
241.9
Non-toxic nodular goiter, unspecified
242.00–242.01
Toxic diffuse goiter
242.10–242.11
Toxic uninodular goiter
242.20–242.21
Toxic multinodular goiter
242.30–242.31
Toxic nodular goiter, unspecified
242.40–242.41
Thyrotoxicosis from ectopic thyroid nodule
242.80–242.81
Thyrotoxicosis of other specified origin
242.90–242.91
Thyrotoxicosis without mention of goiter or other cause
246.0–246.3
Other disorders of thyroid
246.8–246.9
Other disorders of thyroid
254.0–254.1
Disease of thymus gland
254.8–254.9
Disease of thymus gland
277.02
Cystic fibrosis with pulmonary manifestations
277.09
Cystic fibrosis with other manifestations
277.30
Amyloidosis, unspecified
277.39
Other amyloidosis
282.60
Sickle-cell disease unspecified
282.62
Hb-ss disease with crisis
282.64
Sickle-cell/hb c disease with crisis
324.0–324.1
Intracranial and intraspinal abscess
353.0
Brachial plexus lesions
358.00–358.01
Myasthenia gravis
358.1–358.2
Myoneural disorders
358.8–358.9
Myoneural disorders
391.0–391.2
Rheumatic fever with heart involvement
393
Chronic rheumatic pericarditis
398.0
Rheumatic myocarditis
415.11–415.12
Acute pulmonary heart disease
415.19
Other pulmonary embolism and infarction
416.0–416.2
Chronic pulmonary heart disease
416.8-416.9
Chronic pulmonary heart disease
417.0–417.1
Other diseases of pulmonary circulation
417.8–417.9
Other diseases of pulmonary circulation
420.0
Acute pericarditis in diseases classified elsewhere
420.90
Acute pericarditis unspecified
422.0
Acute myocarditis in diseases classified elsewhere
422.90
Acute myocarditis unspecified
423.0
Hemopericardium
423.2–423.3
Other diseases of pericardium
423.8–423.9
Other diseases of pericardium
425.1
Hypertrophic obstructive cardiomyopathy
425.4
Other primary cardiomyopathies
425.8
Cardiomyopathy in other diseases classified elsewhere
427.5
Cardiac arrest
428.0–428.1
Heart failure
428.20–428.23
Systolic heart failure
428.30–428.33
Diastolic heart failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure, unspecified
435.2
Subclavian steal syndrome
440.0
Atherosclerosis of aorta
441.00–441.03
Dissection of aorta
441.1–441.7
Aortic aneurysm and dissection
441.9
Aortic aneurysm, of unspecified site without mention of rupture
442.82
Aneurysm, subclavian artery
442.89
Aneurysm, other artery
444.1
Embolism and thrombosis of thoracic aorta
446.20
Hypersensitivity angititis, unspecified
446.4
Wegener’s granulomatosis
447.1–447.2
Other disorders of arteries and arterioles
447.70447.72
Other disorders of arteries and arterioles
452
Portal vein thrombosis
453.0
Budd-Chiari syndrome
453.2
Embolism and thrombosis of inferior vena cava
453.77
Chronic venous embolism and thrombosis of other thoracic veins
453.87
Acute venous embolism and thrombosis of other thoracic veins
456.0-456.1
Varicose veins of other sites
459.2
Compressions of vein
478.31
Unilateral partial paralysis of the vocal chords
480.0–480.3
Viral pneumonia
480.8–480.9
Viral pneumonia
481
Pneumococcal pneumonia
482.0–482.2
Other bacterial pneumonia
482.30–482.32
Pneumonia due to streptococcus
482.39
Pneumonia due to streptococcus, other
482.40–482.42
Pneumonia due to staphylococcus
482.49
Other staphylococcus pneumonia
482.81–482.84
Pneumonia due to other specified bacteria
482.89
Pneumonia, other specified bacteria
482.9
Bacterial pneumonia, unspecified
483.0–483.1
Pneumonia due to other specified organism
483.8
Pneumonia due to other specified organism
484.1
Pneumonia in cytomegalic inclusion disease
484.3
Pneumonia in whooping cough
484.5–484.8
Pneumonia in infectious diseases classified elsewhere
485
Bronchopneumonia, organism unspecified
486
Pneumonia, organism unspecified
487.0–487.1
Influenza
487.8
Influenza with other manifestations
490
Bronchitis, not specified as acute or chronic
491.1
Mucopurulent chronic bronchitis
491.21
Obstructive chronic bronchitis with (acute) exacerbation
491.8
Other chronic bronchitis
492.0
Emphysematous bleb
492.8
Other emphysema
494.0–494.1
Bronchiectasis
495.0–495.9
Extrinsic allergic alveolitis
496
Chronic airway obstruction, not elsewhere classified
500
Coal workers’ pneumoconiosis
501
Asbestosis
502
Pneumoconiosis due to other silica or silicates
503
Pneumoconiosis due to other inorganic dust
504
Pneumonopathy due to inhalation of other dust
505
Pneumoconiosis, unspecified
506.0–506.4
Respiratory conditions due to chemical fumes and vapors
506.9
Unspecified respiratory conditions due to chemical fumes and vapors
507.0–507.1
Pneumonitis due to solids and liquids
507.8
Pneumonitis due to other solids and liquids
508.0–508.1
Respiratory conditions due to other and unspecified external agent
508.8–508.9
Respiratory conditions due to other and unspecified external agent
510.0
Empyema with fistula
510.9
Empyema without mention of fistula
511.0–511.1
Pleurisy
511.81
Malignant pleural effusion
511.89
Other specified forms of effusion, except tuberculous
511.9
Unspecified pleural effusion
512.0–512.1
Pneumothorax
512.8
Other spontaneous pneumothorax
513.0–513.1
Abscess of lung and mediastinum
514
Pulmonary congestion and hypostasis
515
Post-inflammatory pulmonary fibrosis
516.0–516.3
Other alveolar and pariteoalveolor pneumonopathy
516.8–516.9
Other alveolar and pariteoalveolor pneumonopathy
517.1–517.3
Lung involvement in conditions classified elsewhere
517.8
Lung involvement in other diseases classified elsewhere
518.0–518.7
Other diseases of lung
518.81–518.84
Other diseases of lung
518.89
Other diseases of lung, not elsewhere classified
519.11
Acute bronchospasm
519.19
Other diseases of trachea and bronchus
519.2
Mediastinitis
530.0
Achalasia and cardiospasm
530.20–530.21
Ulcer of esophagus
530.3–530.7
Diseases of esophagus
530.84
Tracheoesophageal fistula
551.3
Diaphragmatic hernia with gangrene
552.3
Diaphragmatic hernia with obstruction
553.3
Diaphragmatic hernia without obstruction or gangrene
567.1
Pneumococcal peritonitis
567.21–567.23
Other suppurative peritonitis
567.29
Other suppurative peritonitis
567.81
Choleperitonitis
567.9
Unspecified peritonitis
577.0–577.2
Diseases of pancreas
577.8–577.9
Diseases of pancreas
610.0–610.4
Benign mammary dysplasias
610.8–610.9
Benign mammary dysplasias
611.0
Inflammatory disease of breast
611.3
Fat necrosis of breast
611.5–611.6
Other disorders of breast
611.71–611.72
Other disorders of breast
611.79
Other disorders of breast
710.0–710.1
Diffuse diseases of connective tissue
714.81
Rheumatoid lung
746.89
Other specified anomalies of heart
746.9
Unspecified anomaly of heart
747.0
Patent ductus arteriosus
747.10–747.11
Coarctation of aorta
747.20–747.22
Other anomalies of aorta
747.29
Other anomalies of aorta
747.3
Congenital anomalies of pulmonary artery
747.40–747.42
Anomalies of great veins
747.49
Other anomalies of great veins
748.3–748.5
Congenital anomalies of respiratory system
748.60–748.61
Other anomalies of lung
748.9
Unspecified congenital anomaly of respiratory system
750.3–750.4
Other congenital anomalies of upper alimentary tract
754.2
Certain congenital musculoskeletal deformities of spine
754.81–754.82
Other specified non-teratogenic anomalies
756.6
Congenital anomalies of diaphragm
759.82
Marfan syndrome
770.7
Chronic respiratory disease arising in the perinatal period
770.87–770.88
Other respiratory problems after birth
784.40–784.41
Voice disturbance
784.49
Other voice and resonance disorders
785.0–785.4
Symptoms involving cardiovascular system
785.50–785.52
Shock without mention of trauma
785.6
Enlargement of lymph nodes
786.00–786.07
Dyspnea and respiratory abnormalities
786.09
Other dyspnea and respiratory abnormalities
786.1
Stridor
786.2
Cough
786.30
Hemoptysis, unspecified
786.39
Other hemoptysis
786.4
Abnormal sputum
786.50–786.52
Chest pain
786.59
Chest pain, other
786.6–786.9
Symptoms involving respiratory system and other chest symptoms
789.00–789.07
Abdominal pain
789.1–789.2
Other symptoms involving abdomen and pelvis
789.30–789.37
Abdominal or pelvic swelling, mass or lump
789.39
Abdominal or pelvic swelling, mass or lump, other specified site
789.51
Malignant ascites
789.59
Other ascites
793.1–793.2
Non-specific abnormal findings on radiological and other examination of body structure
793.91
Image test inconclusive due to excess body fat
793.99
Other non-specific (abnormal) findings on radiological and other examination of body structure
794.2
Non-specific abnormal results of function study of pulmonary system
794.30
Unspecified abnormal function study of cardiovascular system
807.00–807.09
Fracture of rib(s), closed
807.10–807.19
Fracture of rib(s), open
807.2–807.6
Fracture of rib(s), sternum, larynx and trachea
819.0–819.1
Multiple closed fractures involving both upper limbs and upper limb with rib(s) and sternum
860.0–860.5
Traumatic pneumothorax and hemothorax
861.00–861.03
Injury to heart without mention of open wound into thorax
861.10–861.13
Injury to heart with open wound into thorax
861.20–861.22
Injury to lung without mention of open wound into thorax
861.30–861.32
Injury to lung with open wound into thorax
862.0–862.1
Injury to other and unspecified intrathoracic organs
862.21–862.22
Injury to other and specified intrathoracic organs, without mention of open wound into cavity
862.29
Injury to other and specified intrathoracic organs, without mention of open wound into cavity, other
862.31–862.32
Injury to other and specified intrathoracic organs, with open wound in cavity
862.39
Injury to other and specified intrathoracic organs, with open wound in cavity, other
862.8–862.9
Injury to other and unspecified intrathoracic organs
875.0–875.1
Open wound of chest (wall)
879.6–879.7
Open wound of other and unspecified parts of trunk
901.0–901.3
Injury to blood vessels of thorax
901.40–901.42
Injury to pulmonary vessel(s)
901.81
Injury to intercostal artery or vein
901.89
Injury to other specified blood vessels of thorax
901.9
Injury to unspecified blood vessel of thorax
906.0
Late effect of open wound of head neck and trunk
908.0
Late effect of internal injury to chest
908.4
Late effect of injury to blood vessel of thorax, abdomen and pelvis
922.1
Contusion of chest wall
926.8
Crushing injury of multiple sites of trunk
934.0–934.1
Foreign body in trachea, bronchus and lung
934.8–934.9
Foreign body in trachea, bronchus and lung
958.0–958.1
Certain early complications of trauma
958.3–958.4
Certain early complications of trauma
958.7
Traumatic subcutaneous emphysema
959.11
Other injury of chest wall
996.00
Mechanical complications of unspecified cardiac device implant and graft
996.83–996.84
Complications of transplanted organ
V10.00
Personal history of malignant neoplasm of unspecified site in gastrointestinal tract
V10.03–V10.05
Personal history of malignant neoplasm
V10.11–V10.12
Personal history of malignant neoplasm of trachea, bronchus and lung
V10.20–V10.21
Personal history of malignant neoplasm of other respiratory and intrathoracic organs
V10.29
Personal history of malignant neoplasm of other respiratory and intrathoracic organs
V10.3
Personal history of malignant neoplasm of breast
V10.40
Personal history of malignant neoplasm of unspecified female genital organ
V10.45
Personal history of malignant neoplasm of unspecified male genital organ
V10.52
Personal history of malignant neoplasm of kidney
V10.71–V10.72
Personal history of other lymphatic and hematopoietic neoplasms
V10.79
Personal history of other lymphatic and hematopoietic neoplasms
V18.19
Family history of other endocrine and metabolic diseases
V67.00
Follow-up examination following unspecified surgery
V67.09
Follow-up examination following other surgery
V67.1–V67.2
Follow-up examination
V71.1
Observation for suspected malignant neoplasm
V71.82–V71.83
Observation/evaluation, other specified suspected conditions
V71.89
Observation/evaluation, other specified suspected conditions
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

Utilization Guidelines
Reordering Identical Type of Imaging Examination: No imaging examination (pertaining to an identical CPT code only) should be ordered more frequently than six times per calendar year. This frequency limit does not apply to the inpatient setting.
More frequent (more than six times per calendar year) imaging may be covered on an LCD individual considerationbasis. It is the responsibility of the requesting provider to carefully document that more frequent imaging will provide essential diagnostic information, which will directly impact treatment decision-making. LCDindividual considerations may be requested for additional medically necessary examinations, which are performed to restage after a course of treatment has been completed to detect residual disease or suspected recurrence/metastasis. Medical records submitted with the LCD individual consideration request should contain the course of treatment(s) completed, along with the patient’s clinical response (if available) and the need for continued clinical management based on the additional imaging findings.
These LCD individual consideration redetermination instructions are described in the attached article.

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