N28.84 — Pyelitis cystica
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document that the ultrasound was limited to retroperitoneal structures when billing CPT 76770/76775/76776, including images/findings demonstrating limitation to the retroperitoneum.
- If the exam was expanded to include organs outside the retroperitoneum, documentation must reflect the expansion and support billing a full or limited abdominal ultrasound (CPT 76700/76705/76706).
- Claims and documentation should follow the complementary Local Coverage Determination L34577 and any applicable LCD requirements.
- Policy defines complete versus limited retroperitoneal ultrasound studies (complete visualizes all structures in the anatomic description; limited images a single quadrant, single diagnostic problem, or specific organ) but does not specify exact documentation forms or prior authorization requirements.
Key Coverage Criteria
- Retroperitoneal ultrasound (CPT 76770, 76775, 76776) is covered when the exam is limited solely to retroperitoneal structures.
- A full (complete) or limited abdominal ultrasound (CPT 76700, 76705, 76706) is covered when the exam includes organs or structures outside the retroperitoneum or when primary findings involve non-retroperitoneal structures (e.g., gallbladder, liver, spleen, common bile duct).
- Retroperitoneal ultrasound is indicated for evaluation of the pancreas for diagnosis and management of retroperitoneal abnormalities.
- Retroperitoneal ultrasound is indicated to measure and follow the abdominal aorta, including monitoring patients with aortic aneurysms.
- Retroperitoneal ultrasound is indicated to assess the inferior vena cava for tumor invasion and to identify levels of obstruction.
- Retroperitoneal ultrasound is indicated to confirm scarred or small kidneys in chronic renal cortical disease.
4 Active Policies
AETNA-CPB-0492 — Radiofrequency Tumor Ablation
ANTHEM-CG-LAB-30 — CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing
A55336 — Billing and Coding: Retroperitoneal Ultrasound
L34577 — Retroperitoneal Ultrasound
Related Codes
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