ABDOMEN IMAGING GUIDELINES MedSolutions, Inc. Clinical Decision Support Tool

Transcription

MedSolutions, Inc.
This tool addresses common symptoms and symptom complexes. Imaging requests for patients with atypical
Clinical Decision Support Tool symptoms or clinical presentations that are not specifically addressed will require physician review.
Diagnostic Strategies
Consultation with the referring physician, specialist and/or patient’s Primary Care Physician (PCP) may
provide additional insight.
ABDOMEN IMAGING GUIDELINES
Version 16.0; Effective 02-21-2014
MedSolutions, Inc. Clinical Decision Support Tool
for Advanced Diagnostic Imaging
Common symptoms and symptom complexes are addressed by this tool. Imaging requests for patients with atypical
symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation
with the referring physician may provide additional insight.
This version incorporates MSI accepted revisions prior to 12/31/13
CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit
codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic
units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or
dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.
©
2014 MedSolutions, Inc.
Abdomen Imaging Guidelines
Page 1 of 73
ABDOMEN Imaging Guidelines Number and Title
Abbreviations
GENERAL ABDOMINAL SIGNS and SYMPTOMS (Alphabetical Order)
AB-1~General Guidelines
4
AB-2~Abdominal Pain, Generalized
11
AB-3~Abdominal Sepsis (Suspected Abdominal Abscess)
12
AB-4~Epigastric Pain, Dyspepsia, Gastritis, and Postprandial Fullness
13
AB-5~Flank Pain, Rule Out Renal Stone
14
AB-6~Gastroenteritis
16
AB-7~Left Lower Quadrant Pain, Rule Out Diverticulitis
17
AB-8~Left Upper Quadrant Pain
18
AB-9~Mesenteric – Colonic Ischemia
19
AB-10~Post-Operative Pain – Within 60 Days Following Abdominal Surgery
20
AB-11~Right Lower Quadrant Pain, Rule Out Appendicitis
21
AB-12~Right Upper Quadrant pain, Rule Out Cholecystitis
MISCELLANEOUS ABDOMINAL ENTITIES (Alphabetical Order)
AB-13~Abdominal Lymphadenopathy
22
23
AB-14~Bariatric Surgery
23
AB-15~Blunt Abdominal Trauma
24
AB-16~Gaucher’s Disease and Hemochromatosis
25
AB-17~Hernias
26
AB-18~Lipomas
28
AB-19~Lower Extremity Edema
28
AB-20~Zollinger-Ellison Syndrome (ZES)
SPECIFIC ABDOMINAL ORGANS - STRUCTURES
AB-21~Adrenal Cortical Lesions
AORTA
29
5
30
AB-22~Abdominal Aortic Aneurysm (AAA), Iliac Artery Aneurysm (IAA) & Visceral
Artery Aneurysms – Follow Up of Known Anuerysms and Pre-Operative Evaluation
34
AB-23~Abdominal Aortic Aneurysm (AAA), Iliac Artery Aneurysm (IAA) – Post
Endovascular or Open Aortic repair
37
AB-24~Aortic Dissection and Imaging for Other Aortic Conditions
38
Table of Contents Continued Next Page . . .
Version 16.0; Effective 02-21-2014 Abdomen
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ABDOMEN IMAGING GUIDELINES Continued . . .
ABDOMEN Imaging Guidelines Number and Title
BOWEL (Alphabetical Order)
AB-25~Bowel Obstruction
39
AB-26~Diarrhea – Constipation and Irritable Bowel
40
AB-27~GI Bleeding
41
AB-28~Imflammatory Bowel Disease, Rule Out Crohn’s Disease or Ulcerative Colitis
42
AB-29~Celiac Disease (Sprue)
43
AB-30~CT Colonography (CTC)
44
LIVER
AB-31~Cirrhosis and Liver Screening for Hepatocellular Carcinoma (HCC)
45
AB-32~MR Cholangiopancreatography (MRCP)
47
AB-33~Jaundice
49
AB-34~Liver Lesion Characterization
50
AB-35~Elevated Liver Function (LFT) Levels
52
AB-36~Rule Out Liver Metastasis
See:ONC-5~Metastatic Cancer and Carcinomas of Unknown Primary Site
53
PANCREAS and SPLEEN
AB-37~Pancreatic Lesion
54
AB-38~Pancreatic Pseudocysts
55
AB-39~Pancreatitis
56
AB-40~Spleen
58
RENAL
AB-41~Indeterminate Renal Lesion
60
AB-42~Renal Failure
63
AB-43~Renovascular Hypertension
64
AB-44~Polycystic Kidney Disease
65
URINARY TRACT
AB-45~Hematuria
66
AB-46~Urinary Tract Infection (UTI)
68
AB-47~Patent Urachus
70
TRANSPLANT
AB-48~Transplant
71
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Page 3 of 73
ABBREVIATIONS for ABDOMEN IMAGING GUIDELINES
AAA
ACE
ACTH
AFP
ALT
AST
BEIR
BUN
CNS
CT
CTA
CTC
DVT
ERCP
FNH
GFR
GGT
GI
HCC
HCPCS
HU
IAA
KUB
LFT
MRCP
MRA
MRI
mSv
NAFLD
PA
PET
RAS
RBC
SBFT
SPECT
VC
PFT
WBC
ZES
abdominal aortic aneurysm
angiotensin-converting enzyme
adrenocorticotropic hormone
alpha-fetoprotein
alanine aminotransferase
aspirate aminotransferase
Biological Effects of Ionizing Radiation
blood urea nitrogen
central nervous system
computed tomography
computed tomography angiography
computed tomography colonography (aka: virtual colonoscopy)
deep vein thrombosis
endoscopic retrograde cholangiopancreatography
focal nodular hyperplasia
glomerular filtration rate
gamma glutamyl transferase
gastrointestinal
hepatocellular carcinoma
Healthcare Common Procedural Coding System (commonly pronounced: “hix pix”)
Hounsfield units
iliac artery aneurysm
IV intravenous
kidneys, ureters, bladder (plain frontal supine abdominal radiograph)
liver function tests
magnetic resonance cholangiopancreatography
magnetic resonance angiography
magnetic resonance imaging
millisievert
nonalcoholic fatty liver disease
posteroanterior projection
positron emission tomography
renal artery stenosis
red blood cell
small bowel follow through
single photon emission computed tomography
virtual colonoscopy (CT colonography)
pulmonary function tests
white blood cell
Zollinger-Ellison Syndrome
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Page 4 of 73
AB-1~GENERAL GUIDELINES
AB-1
General Guidelines
1.1 Overview
6
1.2 CT Imaging
7
1.3 MR Imaging
8
1.4 MR Enterography Coding Notes
8
1.5 Ultrasound
8
1.6 Abdominal Ultrasound
9
1.7 Retroperitoneal Ultrasound
9
1.8 CT-, MR-, Ultrasound-guided Procedures
10
1.9 Special Considerations
10
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Page 5 of 73
AB-1~GENERAL GUIDELINES
AB-1.1 Overview
 A current clinical evaluation (within 60 days) is required before advanced imaging can
be considered. The clinical evaluation may include a relevant history and physical
examination, appropriate laboratory studies, and non-advanced imaging modalities
such as plain x-ray or ultrasound. Other meaningful contact (telephone call, electronic
mail or messaging) by an established patient can substitute for a face-to-face clinical
evaluation.
 GI Specialist evaluations can be helpful, particularly in determining
mesenteric/colonic ischemia, diarrhea/constipation, irritable bowel syndrome, or need
for MRCP.
 Conservative treatment for abdominal pain can include (list is not exhaustive):
o Anti-secretory or H. Pylori medications
o Non-steroidal or opiate analgesia
o Plain abdominal radiography
o Diet modification
o Pro- or anti-motility agents
 Abdominal imaging begins at the diaphragm and extends to the umbilicus or iliac
crest.
 Pelvic imaging begins at the iliac crest and extends to the pubis.
 Clinical concerns at the dividing line can be providers’ choice (abdomen and pelvis;
abdomen or pelvis)
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AB-1.2 CT Imaging
 CT imaging is a more generalized modality. Abdominal CT is usually performed with
contrast (CPT®74160):
o Oral contrast has no relation to the IV contrast administered.
o Exceptions are noted in these guidelines, and include:
 Abdominal CT without and with contrast (CPT®74170) with suspicion of a
solid organ lesion (liver, kidney, pancreas, spleen)
 Abdominal CT without contrast (CPT®74150) or Abdomen and Pelvis CT
(CPT®74176) if there is renal insufficiency/failure, or a documented allergy to
contrast. It can also be considered for diabetics or the very elderly.
o Abdomen with Pelvis CT, usually with contrast (CPT®74177), should be
considered when signs or symptoms are generalized or lower quadrant abdomen or
pelvic.
o CT Enterography (CPT®74177) combines CT imaging with large volumes of
ingested neutral bowel contrast material to allow visualization of the small bowel
 Usually, only 2D reformatting is used (coronal reformatted images)
 If the 3D rendering codes are requested (CPT®76376 or CPT®76377), then the
final radiology report should be obtained first to verify that true 3D rendering
was performed.
 Also see AB-28~Inflammatory Bowel Disease
o CT Enteroclysis
 A tube is placed through the nose or mouth and advanced into the duodenum or
jejunum. Bowel contrast material is infused through the tube and CT imaging is
performed either with or without intravenous contrast.
 CT enteroclysis is used to allow visualization of the small bowel wall and
lumen. CT enteroclysis may allow better or more consistent distention of the
small bowel than CT enterography.
 Report by assigning: CPT®74176 or CPT®74177
 Usually, only 2D reformatting is used (coronal reformatted images).
 The final radiology report should be obtained first to verify that true 3D
rendering was performed when 3D rendering codes are requested (CPT®76376
or CPT®76377).
o Also see: AB-28~Inflammatory Bowel Disease
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Page 7 of 73
AB-1.3 MR Imaging
 MRI may be preferred as a more targeted study, in cases of renal failure; in patients
allergic to intravenous CT contrast; and as noted in these guidelines.
o MRI of the abdomen with contrast only is essentially never performed. If contrast
is indicated, MRI abdomen without and with contrast (CPT®74183) should be
performed.
o For pregnant women ultrasound or MRI without contrast should be used to avoid
radiation exposure. The use of gadolinium contrast agents is contraindicated during
pregnancy unless the specific need for that procedure outweighs risk to the fetus.1,2
AB-1.4 MR Enterography Coding Notes
 In the absence of written payor claims/billing guidelines, MRI Enterography is
reported in one of two ways:
o MRI Abdomen with and without contrast (CPT®74183), or
o MRI Abdomen with and without contrast (CPT®74183) and MRI Pelvis with and
without contrast (CPT®72197)
AB-1.5 Ultrasound
 Ultrasound, also called sonography, uses high frequency sounds waves to image body
structures.
o The routine use of 3D and 4D rendering, (post-processing), in conjunction with
ultrasound is considered investigational.
o All ultrasound studies require permanently recorded images either stored on film or
in a Picture Archiving and Communication System (PACS).
o The use of a hand-held or any Doppler device that does not create a hard-copy
output is considered part of the physical examination and is not separately billable.
This exclusion includes devices that produce a record that does not permit analysis
of bi-directional vascular flow.
 Duplex scan describes an ultrasonic scanning procedure for characterizing the pattern
and direction of blood flow in arteries and veins with the production of real-time
images integrating B-mode two dimensional vascular structures, Doppler spectral
analysis, and color flow Doppler imaging.
o The minimal use of color Doppler alone, when performed for anatomical structure
identification during a standard ultrasound procedure, is not separately
reimbursable.
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Page 8 of 73
AB-1.6 Abdominal Ultrasound
 Complete abdominal ultrasound (CPT®76700) includes all of the following required
elements:
o Liver, gallbladder, common bile duct, pancreas, spleen, kidneys, upper abdominal
aorta and inferior vena cava.
o If a particular structure or organ cannot be visualized, the report should document
the reason.
 Limited abdominal ultrasound (CPT®76705) is without all of these required elements
and can refer to a specific study of a single organ, a limited area of the abdomen, or a
follow-up study
o Further, CPT®76705 should:
 be assigned to report follow-up studies once a complete abdominal ultrasound
(CPT®76700) has been performed
 be assigned to report ultrasonic evaluation of diaphragmatic motion
 be reported only once per patient imaging session
 not be reported with CPT®76700 for the same patient for the same imaging
session
AB-1.7 Retroperitoneal Ultrasound
 Complete retroperitoneal ultrasound (CPT®76770) includes all of the following
required elements:
o Kidneys, lymph nodes, abdominal aorta, common iliac artery origins, inferior vena
cava
o For urinary tract indications, a complete study can consist of kidneys and bladder
 Limited retroperitoneal ultrasound (CPT®76775) studies are without all of these
required elements and can refer to a specific study of a single organ, a limited area of
the abdomen, or a follow-up study
o Further, CPT®76775 should:
 be assigned to report follow-up studies once a complete abdominal ultrasound
(CPT®76770) has been performed
 be reported only once per patient imaging session
 not be reported with CPT®76700 for the same patient for the same imaging
session
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AB-1.8 CT-, MR-, Ultrasound-guided Procedures
See: Preface-4.2 CT-, MR-, or Ultrasound-Guided Procedures
AB-1.9 Special Considerations
 CT of the abdomen and pelvis either with or without contrast (CPT®74177 or
CPT®74176) can be performed prior to endoscopy if requested by the physician who
will be performing the endoscopy, especially if there is suspected inflammatory bowel
disease.
 Persistent unexplained nausea and vomiting:
o One non-contrast brain MRI (CPT® 70551) can be performed in patients with
persistent, unexplained nausea and vomiting and a negative GI evaluation. See:
HD-1.8 Other Imaging Situations in the Head Imaging Guidelines.
 Fever of unknown origin; Unexplained weight loss
o In the Oncology Imaging Guidelines, refer to:
ONC-4~Medical Conditions with Cancer in the Differential Diagnosis
 Suspected Ascites should be initially evaluated by ultrasound
o Ultrasound (CPT®76700 or CPT®76705) results can then determine the need for
peritoneal fluid analysis or further imaging specific to the findings.3,4
References
1. ACR –SPR Practice Guideline for the Safe and Optimal Performance of Fetal Magnetic Resonance
Imaging, 2012
2. ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with
Ionizing Radiation, 2012
3. Runyon B. Management of adult patients with Ascites due to Cirrhosis: An update. Hepatology,
2009, 49(6), 2087-2107.
4. Berzigotti A, Ashkenazi E, Reverter E, Abraldes JG, Bosch J. Non-invasive diagnostic and
prognostic evaluation of liver cirrhosis and portal hypertension. Disease Markers, 2011, 31(3), 12938.
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GENERAL ABDOMINAL SIGNS and SYMPTOMS
AB-2~ABDOMINAL PAIN, Generalized
AB-2.1 Abdominal Pain, Generalized
 Ultrasound (CPT®76700 or CPT®76705) should be considered for the initial imaging
study of:
o Upper quadrant (right or left) or epigastric pain since ultrasound is useful in
detecting gallbladder and other hepatobiliary pathology, renal lesions, ascites,
splenic pathology, and sometimes adrenal lesions.
o Nondiagnostic or an abnormal ultrasound can help determine the most appropriate
advanced imaging modality based on location of pain abdominal (CT, MRI or
MRCP, etc.).1
o Ultrasound (CPT®76700 and CPT®76830 and/or CPT®76856) should be the initial
imaging study in women with ovaries or uterus intact who present with generalized
abdominal pain, especially if symptoms are located predominately in the lower
abdominal area, in order to rule out gynecological pathology.
 Ultrasound is inappropriate for these women if any of the below signs and
symptoms are present.
 MRI should be used in pregnant women with acute abdominal pain and
equivocal ultrasound and as determined by these guidelines.2
 CT of the abdomen and pelvis with contrast (CPT®74177) can be performed for
abdominal pain and at least one of the following:
o Specific signs and symptoms
 Fever (101 degrees or greater)
 Mass
 GI bleeding
 Moderate to severe abdominal tenderness
 Guarding, rebound tenderness, or other peritoneal signs
 WBC 10,000 or above
o Persistent abdominal pain with failure of conservative treatment for 4 weeks
o Cancer history
 Patients with severe abdominal pain disproportionate to clinical findings can undergo
mesenteric CTA or MRA (CPT®74175 or CPT®74185) if plain x-rays and/or
abdominal CT are negative (see AB-9~Mesenteric/Colonic Ischemia).
 Repeat imaging in patients with unchanged signs or symptoms is not needed.
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References
1. ACR Practice Guidelines for the performance of an ultrasound examination of the abdomen and/or
retroperitoneum, revised 2012.
http://www.acr.org/~/media/EB1DE1E460AA44F485735D75683DE5F6.pdf (accessed June 4,
2013).
2. Birchard KR, Brown MA, Hyslop WB, Firat Z, Semelka RC. MRI of Acute Abdominal and Pelvic
Pain in Pregnant Patients. American Journal of Roentgenology. 2005;184:452-458.
AB-3~ABDOMINAL SEPSIS
(Suspected Abdominal Abscess)
AB-3.1 Abdominal Sepsis
 CT abdomen and/or pelvis with contrast (CPT®74160, or CPT®72193, or CPT®74177)
for abdominal symptoms associated with fever and/or elevated white blood cell
count.1
 Serial Ultrasound (CPT®76705) or CT with contrast (CPT®74160, or CPT®72193, or
CPT®74177) for follow-up of known fluid collections, especially with catheter
drainage. The interval can be days, weeks, or months, but not to exceed 3 follow-up
studies, based on the clinical course of the individual
References
1. Yaghmai V, Rosen MP, Lalani T, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® acute (nonlocalized) abdominal pain and fever or suspected abdominal
abscess. American College of Radiology (ACR); 2012.
2. http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteAbdominalPainFeverSu
spectedAbdominalAbscess.pdf (accessed June 5, 2013).
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AB-4~Epigastric Pain, Dyspepsia, Gastritis, and
Postprandial Fullness
AB-4.1 Epigastric Pain, Dyspepsia, Gastritis, Postprandial Fullness
 Ultrasound (CPT®76700 or CPT®76705) should be considered the initial imaging
study in patients who present with epigastric pain.1
 Advanced imaging with CT or MRI based upon predominant symptom and/or GI
consultation/Upper Endoscopy if
o Antisecretory and/or H. pylori medications for 4 weeks have not relieved signs and
symptoms
 Anemia, weight loss, progressive dysphagia, bleeding, family history of GI
cancer, abnormal labs, or history of GI disease
References
http://www.acr.org/~/media/EB1DE1E460AA44F485735D75683DE5F6.pdf (accessed June 4, 2013).
2. Talley NJ, Vakil N, and the Practice Parameters Committee of the American College of
Gastroenterology. Guidelines for the management of dyspepsia. American Journal of
Gastroenterology, 2005; 100:2324–2337.
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AB-5~FLANK PAIN, Rule Out Renal Stone
AB-5.1 Flank Pain, Rule out Renal Stone
 Low Suspicion Renal Stone (flank pain/renal colic, without hematuria or history of
renal stones)
o Initial imaging study - Ultrasound (CPT®76770 or CPT®76775)
 High Suspicion of Renal Stone in non-pregnant adults (flank pain/renal colic, with
hematuria and/or history renal stones)1,2
o CT Urogram (abdomen and pelvis CT without and with contrast—CPT®74178) if
> 40 years old; OR
o Abdomen and Pelvis CT scan without contrast (renal stone protocol--CPT®74176)
in all others ≤ 40
 High Suspicion of Renal Stone in pregnant women (flank pain/renal colic, with
hematuria and/or history renal stones)3,4
o Ultrasound (CPT®76770 or CPT®76775) or Abdomen and Pelvis MRI without
contrast.
 The use of gadolinium contrast agents is contraindicated during pregnancy
unless the specific need for that procedure outweighs risk to the fetus.
 High Suspicion of Renal Stone in Children (flank pain/renal colic, with hematuria
and/or history renal stones)4
o Ultrasound (CPT®76770 or CPT®76775) or MR urography (MRI abdomen and
pelvis, with or without contrast [CPT®74182/72196 or CPT®74181/72195] is the
best initial study to avoid radiation exposure.
AB-5.2 Follow-Up
 Serial CT scans to determine the passage or dissolution (of uric acid stones) of kidney
stones are acceptable if they do not exceed three scans in a six week period.
o If the stone has been seen on the pelvic CT portion of the CT scan, the subsequent
CT scan(s) should only include the pelvis.
 Post-procedure follow-up should up to 12 months, with CT abdomen and pelvis
without contrast if:
o Uric acid stones, calcified stones obscured on plain films, or stones <4 mm Noncontrast CT abdomen and/or pelvis (CPT®74176, or CPT®74150, or
CPT®72192)
 Non-Uric Acid Stones - Abdomen plain films every 6 to12 months in
asymptomatic patients.
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o For surgical complications or if the individual develops unusual symptoms - CT
abdomen and pelvis without and with contrast (CPT®74178) may be performed.
References
1. Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging
in the management of ureteral calculous disease: AUA technology assessment. American
Urological Association Guideline, 2012. http://www.auanet.org/common/pdf/education/clinicalguidance/Imaging-Assessment.pdf, (accessed June 5, 2013).
2. Coursey CA, Casalino DD, Remer EM, Arellano RS, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® acute onset flank pain -suspicion of stone disease. American College of
Radiology (ACR); 2011. 7 p.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteOnsetFlankPainSuspicio
nStoneDisease.pdf, (accessed June 5, 2013).
3. ACR –SPR Practice Guideline for the Safe and Optimal Performance of Fetal Magnetic Resonance
Imaging, 2012
4. ACR Practice Guideline for Imaging Pregnant or Potentially Pregnant Adolescents and Women with
Ionizing Radiation, 2012
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AB-6~GASTROENTERITIS
Gastroenteritis is generally defined as diarrhea with nausea and vomiting usually with an
infectious etiology.1
AB-6.1 Gastroenteritis
 CT abdomen and pelvis with contrast (CPT®74177) if:
o Acute abdomen suggesting bowel obstruction, toxic megacolon (abdominal
swelling, fever, tachycardia, elevated white blood cell count), or perforation
o Persistent abdominal pain with failure of conservative treatment for 4 weeks
Reference
1. Scorza K, Williams A, Phillips D, Shaw J. Evaluation of Nausea and Vomiting. American Family
Physician, 2007, 76(1):76-84.
2. DuPont HL and the Practice Parameters of the American College of Gastroenterology. Guideline on
acute infectious diarrhea in adults. The American Journal of Gastroenterology, 1997; 92: 1962-1975.
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AB-7~LEFT LOWER QUADRANT PAIN,
Rule Out Diverticulitis
AB-7.1 Left Lower Quadrant Pain, Rule out Diverticulitis
 CT Abdomen and Pelvis with contrast (CPT®74177) for patients with known or
suspected diverticulitis, with any one of the following1:
o Severe abdominal pain
o Mass
o Nausea/vomiting
o Fever (101 degrees or greater)
o Abdominal tenderness
o White blood cell count (10,000 or greater)
o Previous history of diverticulitis
o Persistent pain with failure of conservative treatment after one week
o Prior to endoscopy if requested by the physician who will be performing the
endoscopy.
 Women of child bearing age (<45 years old) who still have ovaries or uterus intact,
should be considered for pelvic ultrasound (CPT®76830 and/or CPT®76856) as the
initial imaging study for detecting gynecologic abnormalities that may cause left
lower quadrant pain.
 Intraperitoneal abscess can undergo interval CT abdomen and pelvis with contrast
(CPT®74177) (See AB-3~Abdominal Sepsis).
 Rectal bleeding and heme positive stools with mild pain can proceed to colonoscopy
first prior to advanced imaging with CT
(See AB-27~GI Bleeding).
Reference
1. Miller FH, Rosen MP, Lalani T, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® left lower quadrant pain - suspected diverticulitis. American College of
Radiology (ACR); 2011. 5 p.
http://gm.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonGas
trointestinalImaging/LeftLowerQuadrantPainDoc8.aspx (accessed June 5, 2013).
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AB-8~LEFT UPPER QUADRANT PAIN
AB-8.1 Left Upper Quadrant Pain
 Ultrasound (CPT®76700 or CPT®76705) should be considered the initial imaging
study in patients who present with left upper quadrant pain1
(See AB-2~Abdominal Pain, Generalized)
 CT abdomen with contrast with persistent abdominal pain with failure of conservative
treatment for 4 weeks
References
http://www.acr.org/~/media/EB1DE1E460AA44F485735D75683DE5F6.pdf (accessed June 4,
2013).
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AB-9~MESENTERIC/COLONIC ISCHEMIA
AB-9.1 Mesenteric Ischemia
 For acute severe abdominal pain out of proportion to findings on physical exam.
o Abdominal (Mesenteric) CTA (CPT®74175) (preferable), or MRA
(CPT®74185),or CT abdomen and pelvis with contrast (CPT®74177)1,2
 For chronic postprandial abdominal pain and weight loss (chronic) can additionally
undergo:
o Abdominal (Mesenteric) CTA (CPT®74175) or MRA (CPT®74185) after a
preceding CT abdomen/pelvis is negative (documentation must be provided)
 Routine post-procedure imaging following invasive treatment for mesenteric
ischemia (bowel resection, embolectomy, etc.) is not needed in asymptomatic
patients.
 Also see “Mesenteric Ischemia” in: PVD-6~Aortic Disorders, Renal Vascular
Disorders, and Visceral Artery Aneurysms in the Peripheral Vascular Disease
Imaging Guidelines.
AB-9.2 Colonic ischemia (including ischemic colitis)
 CT abdomen and pelvis with contrast (CPT®74177) can be performed for suspicion of
colonic ischemia, abdominal pain, and any one of the following:
o Fever (101 degrees or greater)
o Guarding , rebound tenderness, or other peritoneal signs
o WBC above 10,000
o GI bleeding
 Repeat imaging for asymptomatic or unchanged symptoms, including post-procedure
imaging, is not needed.
 Abdominal CTA (CPT®74175) or MRA (CPT®74185) if requested by a
gastroenterology specialist, vascular surgeon, or interventional radiologist.
Reference
1. Fidelman N, Funaki BS, Ray CE Jr, Burke CT, et al. Expert Panel on Interventional Radiology. ACR
Appropriateness Criteria® radiologic management of mesenteric ischemi. American College of
Radiology (ACR); 2011.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/ImagingOfMesentericIschemia.pd
f accessed June 5, 2013.
2. Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and
metal-analysis. Radiology, 2010; 256: 93-101.
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AB-10~Post-Operative Pain Within 60 Days Following
Abdominal Surgery – Abdominal Procedure
AB-10.1 Post-Op Pain within 60 Days Following AB Surgery/Procedure
 CT abdomen and/or pelvis with contrast (CPT®74177 or CPT®74160 or CPT®72193)
can be performed for suspected postoperative/post procedure complications (For
example bowel obstruction, abscess or anastomotic leak).1,2
 Beyond 60 days postoperatively, see AB-2~Abdominal Pain, Generalized
References
1. Small WC, Rose TA Jr, Rosen MP, Blake MA, et al. Expert Panel on Gastrointestinal Imaging.
ACR Appropriateness Criteria® suspected small-bowel obstruction. American College of Radiology
(ACR); 2010. http://www.acr.org/~/media/832F100277004BC69A8C818C7C9BFF33.pdf, accessed
June 6, 2013.
2. Yaghmai V, Rosen MP, Lalani T, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® acute (nonlocalized) abdominal pain and fever or suspected abdominal
abscess. American College of Radiology (ACR); 2012.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcuteAbdominalPainFeverSu
spectedAbdominalAbscess.pdf, accessed June 6, 2013.
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Page 20 of 73
AB-11~RIGHT LOWER QUADRANT PAIN,
Rule Out Appendicitis
AB-11.1 Right Lower Quadrant Pain, Rule out Appendicitis
Appendicitis is strongly suspected (onset right lower quadrant pain within past 72 hours
that is not improving, tenderness to palpation or guarding in right lower quadrant,
rebound tenderness, elevated white blood cell count, or fever1)
If prior appendectomy, see AB-2~Abdominal Pain, Generalized
For all men, women of non-childbearing age, non-pregnant women:
 CT of the abdomen and pelvis either with contrast (CPT®74177) or without contrast
(CPT®74176)
Women of childbearing age, and pregnant patients:
 Ultrasound (CPT®76700 and CPT®76830 and/or CPT®76856). If positive, no further
diagnostic imaging is necessary.
o MRI without contrast can be performed for pregnant patients if ultrasound is
equivocal.
o See also: AB-1.3 MR Imaging
Children 14 and younger:
 Ultrasound (CPT®76700 and CPT®76830 and/or CPT®76856). If positive, no further
diagnostic imaging is necessary.
o CT of the abdomen and pelvis either with contrast (CPT®74177) if ultrasound is
equivocal
Children older than 14:
 CT of the abdomen and pelvis either with contrast (CPT®74177) or without contrast
(CPT®74176)
If abscess or phlegmon identified:
 CT abdomen and pelvis with contrast (CPT®74177) can be used for follow-up, not to
exceed 3 additional studies
References
1. Rosen MP, Ding A, Blake MA, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® right lower quadrant pain -- suspected appendicitis. American College of
http://gm.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPedi
atricImaging/Othertopics/RightLowerQuadrantPain.aspx, accessed June 6, 2013.
2. Doria AS, Moineddin R, Kellenberger CJ, Epelman M et al. US or CT for diagnosis of appendicitis
in children and adults? A meta-analysis. Radiology, 2006; 241: 83094.
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Page 21 of 73
AB-12~RIGHT UPPER QUADRANT PAIN,
Rule Out Cholecystitis
AB-12.1 Right Upper Quadrant Pain, Rule Out Cholecystitis
 Ultrasound (CPT®76700 or CPT®76705) is considered the initial imaging study in
patients who present with acute right upper quadrant pain
 CT Abdomen with contrast (CPT®74160) or MRI abdomen without or without and
with contrast can be performed if ultrasound is negative or equivocal
References
1. Katz DS, Rosen MP, Blake MA, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® right upper quadrant pain. American College of Radiology (ACR); 2010.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RightUpperQuadrantPain.pdf,
accessed June 6, 2013.
2. Barnes DS. Gallbladder and biliary tract disease. July 9, 2002. Available at:
www.clevelandclinicmeded.com/diseasemanagement, accessed June 6, 2013.
3. Barnes DS. Intrahepatic cholestatic liver disease. July 9, 2002. Available at:
www.clevelandclinicmeded.com/diseasemanagement, accessed June 6, 2013.
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MISCELLANEOUS ABDOMINAL ENTITIES (ALPHABETICAL ORDER)
AB-13~ABDOMINAL LYMPHADENOPATHY
AB-13.1 Abdominal Lymphadenopathy
 CT abdomen with contrast (CPT®74160) or CT abdomen and pelvis with contrast
(CPT®74177) two months following the original imaging study if lymphadenopathy
is:
o Found incidentally on previous imaging, and
o Without associated fever, weight loss, pain, GI bleeding, or other intra-abdominal
findings to raise the suspicion of malignancy
 If enlarged lymph node(s) is still a concern after repeat CT, biopsy should be
considered to establish a histological diagnosis.1, 2
References
1. Bazemore AW, Smucker DR. Lymphadenopathy and malignancy. American Family Physician,
2002, 66(1), 2103-2111.
AB-14~BARIATRIC SURGERY
AB-14.1 Bariatric Surgery
 CT abdomen and pelvis with contrast (CPT®74177) for patients who have had obesity
surgery and suspected complication who present with fever, abdominal pain,
abdominal distention, frequent vomiting or suspected incisional hernia.
 See AB-10~Post-Operative Pain Within 60 Days Following Abdominal Surgery
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AB-15~BLUNT ABDOMINAL TRAUMA
AB-15.1 Blunt Abdominal Trauma
 To determine whether patients need hospitalization for observation as a result of blunt
renal trauma with hematuria, CT abdomen and pelvis without and with contrast
(CPT®74178) should be used initially1,2
 Ultrasound (CPT®76700 and/or CPT®76856) initially for trauma with low probability
of intra-abdominal injury (minimal pain, no peritoneal irritation on physical
examination, no hemodynamic instability, no elevated AST/ALT)
 CT abdomen and/or pelvis with contrast (CPT®74160, or CPT®72193, or
CPT®74177):
o High probability intra-abdominal injury
o If ultrasound demonstrates any positive finding(s)
References
1. Sudakoff GS, Rosen MP, Rybicki FJ, Blake MA, et al. Expert Panels on Vascular Imaging and
Gastrointestinal Imaging. ACR Appropriateness Criteria® blunt abdominal trauma. American
College of Radiology (ACR); 2012.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/BluntAbdominalTrauma.pdf,
2. Soto JA, Anderson SW. Multidetector CT of blunt abdominal trauma. Radiology, 2012;265 :678-93.
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Page 24 of 73
AB-16~GAUCHER’S DISEASE and HEMACHROMATOSIS
See also: PN-6.3 Gaucher’s Disease in the Peripheral Nerve Disorders Imaging
Guidelines
AB-16.1 Gaucher’s Disease
 MRI abdomen without contrast (CPT®74181) and MRI lower extremity without
contrast (CPT®73718) as follows:
o Patients not on enzyme therapy -every 12 to 24 months1
o Patients on enzyme therapy every 12 months:
 For change in dose of medication or clinical complication, individuals with
active bone disease may require more frequent monitoring than once a year.
AB-16.2 Hemachromatosis and Other Iron Storage Diseases
 MRI liver (CPT®74181 or CPT®74183) or heart (CPT®75557 or CPT®75561)
o Confirm liver or cardiac iron stores and for following treatment2,3,4 of
hemochromatosis and other storage diseases.
Practice Notes
Gaucher’s Disease is a lysosomal storage disease with glucosylceramide accumulation in
the spleen, liver, kidneys, lung, brain and bone marrow.
References
1. Weinreb NJ, Aggio MC, Andersson HC, Andria G, et al. Gaucher disease type 1: revised
recommendations on evaluations and monitoring for adult patients. Seminars in Hematology, 2004,
41(4 Suppl 5), 15-22.
2. Bacon BR, Adams PC, Kowdley KV, Powell LW et al. Diagnosis and Management of
Hemochromatosis: 2011 Practice Guideline by the American Association for the Study of Liver
Diseases. Hepatology, 2011, 54(1), 328-343.
3. Taouli B, Ehman RL, Reeder, SB. Advanced MRI Methods for Assessment of Chronic Liver
Disease. American Journal of Roentgenology, 2009, 193(1), 14-27.
4. Penugonda N. Cardiac MRI in Infiltrative Disorders: A Concise Review. Current Cardiology
Reviews, 2010, 6(2), 134-136.
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AB-17~HERNIAS
AB-17.1 Hernia
 Ultrasound is the initial imaging for known or suspected primary or recurrent inguinal
or femoral hernia
 Advanced imaging is unnecessary unless there is suspected incarceration or
strangulation of any hernia or determined by a specialist or surgeon:
o CT pelvis with contrast (CPT®72193) or without contrast (CPT®72192)
 Known or suspected primary or recurrent Spigelian hernia (anterior abdominal wall
hernia through the semilunar line), ventral hernia, umbilical, or incisional hernia:
o CT of the abdomen (and pelvis if below the umbilicus) with contrast (CPT®74160
or CPT®74177) or without contrast (CPT®74150 or CPT®74176).
AB-17.2 Hiatal Hernia
 Chest and/or Abdomen CT with contrast (CPT®71260 and/or CPT®74160) can be
performed to evaluate any of the following:
o GI specialist or surgeon request for treatment/pre-operative planning
o Or suspected complication of primary disease or surgery
AB-17.3 Indeterminate Groin Pain
 Occurs after intrabdominal/genitourinary causes have been ruled out and
Musculoskeletal evaluation does not identify a specific cause
o Plain x-ray of the pelvis is the initial study
o Further advanced imaging can then be considered with pelvis MRI without contrast
o US can be considered in the evaluation of sports hernia (athletic pubalgia)
Practice Note
A sports hernia, also referred to as athletic pubalgia, is not a true hernia. Sports hernia is
a term used to describe a condition characterized by groin pain, often in an athlete, in
which there is no identifiable hernia.
References
1. Daniels CJ, Scali F. Clinical brief: recognition and treatment of the elusive sports hernia. Topics in
Integrative Health Care, 2012; 3(3).
2. ACR Appropriateness Criteria® Palpable Abdominal Mass, 2011
3. Ann R Coll Surg Eng 2003 May;85(3):174-177
4. Surg Endosc 2002 Apr;16(4):659-662
5. Qureshi WA. Hiatal hernia. Medscape, August 24, 2009,
http://emedicine.medscape.com/article/178393-overview. Accessed May 27, 2011
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Page 26 of 73
6. Omar IM, Zoga AC, Kavanagh EC, Koulouris G, et al. Athletic pubalgia and “sports hernia”:
optimal MR imaging technique and findings. RadioGraphics, 2008; 28: 1415-1438.
7. Caudill P, Nyland J, Smith C, Yerasimides J, Lach J. Sports hernias: a systematic literature review.
British Journal of Sports Medicine, 2008; 42(12):954-964.
8. Suarez JC, Ely EE, Mutnal AB, Figueroa NM, Klika AK, et al. Comprehensive approach to the
evaluation of groin pain. Journal of the American Academy of Orthopaedic Surgeons, 2013; 21:558570.
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Page 27 of 73
AB-18~LIPOMA
AB-18.1 Subcutaneous Lipoma
 Subcutaneous lipoma does not require imaging for diagnosis
 Ultrasound should be utilized first if the clinical exam is equivocal
o See in: MS-1~Ultrasound Coding for Examination of a Soft Tissue Mass
(musculoskeletal guidelines)
 CT without and with contrast if lipoma is not subcutaneous or still equivocal after
Ultrasound
 MRI with and without contrast or MRI without contrast can be considered if
ultrasound and/or CT are equivocal, or for preoperative planning1
References
1. Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultrasound for initial evaluation and
triage of clinically suspicious soft-tissue masses. Clin Radiol, 2009; 64: 615-621.
2. Gaskin CM, Helms CA. Lipomas, Lipoma Variants, and Well-Differentiated Liposarcomas
(Atypical Lipomas): Results of MRI Evaluations of 126 Consecutive Fatty Masses. American
Journal of Roentgenology. 2004;182,733-739
3. Einarsdottir H, Soderlund V, Larsson O. 110 subfascial lipomatous tumors. MR and CT findings
versus histopathological diagnosis and cytogenetic analysis. Acta Radiol. Nov 1999;40(6):603-9
4. Zoga AC, Weissman BN, Kransdorf MJ, Adler R, et al. ACR Appropriateness Criteria: Soft Tissue
Masses. American College of Radiology, 2012.
AB-19~LOWER EXTREMITY EDEMA
Also see PVD-7.4 Lower Extremity Edema in the Peripheral Vascular Disease Imaging
Guidelines.
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AB-20~ZOLLINGER-ELLISON SYNDROME (ZES)
AB-20.1 Zollinger-Ellison Syndrome (ZES)
 CT abdomen with contrast (CPT®74160) or MRI abdomen without and with contrast
(CPT®74183)
Practice Notes
Zollinger-Ellison Syndrome is a complex condition in which one or more tumors form in
the pancreas or upper part of the small intestine (duodenum).
Imaging is sometimes combined with Somatostatin Receptor Scintigraphy in the
evaluation of suspected gastrinoma (elevated serum gastrin (normal value is <100 pg/ml)
and/or abnormal gastric acid secretory test).1,2,3
References
1. Gibril F, Reynolds J, Doppman J, et al. Somatostatin receptor scintigraphy: its sensitivity compared
with that of other imaging methods in detecting primary and metastatic gastrinomas: a prospective
study. Ann Intern Med. 1996;125:26-34.
2. Alexander HR, Fraker D, Norton J, et al. Prospective study of somatostatin receptor scintigraphy and
its effect on operative outcome in patients with Zollinger-Ellison syndrome. Ann Surg.
1998;228:228-238.
3. Norton J and Robert J. Resolved and unresolved controversies in the surgical management of
patients with Zollinger-Ellison syndrome. Ann Surg. 2004;240:757-773.
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Page 29 of 73
AB-21~ADRENAL CORTICAL LESIONS
AB-21.1 Adrenal Cortical Lesions
Imaging Decision Tree: Incidentally Discovered Adrenal Mass1,2,3,4
Mass Details
1) 1 to 4 cm;
2) No history
malignancy;
3) Initial
Primary Study
CT abdomen without
contrast (CPT®74150)
Additional Studies
If primary CT without is not
diagnostic or concerning for
malignancy:
-CT abdomen* (CPT®74170); or
-MRI abdomen** (CPT®74181)
Comments:
*delayed imaging obtained to calculate washout
**also appropriate for iodinated contrast allergy
Mass Details
Primary Study
Additional Studies
1) 1-4 cm;
2) No history
CT abdomen without
If enlarging adrenal lesion:
malignancy;
®
contrast (CPT 74150)
-MRI abdomen without
3) Follow-up
contrast (CPT®74181)
indeterminate lesions
in 12 months
Comments:
No further imaging if: (1) initial determines benign adenoma, myelolipoma,
hematoma or simple cyst or (2) no change in size after 12 months follow-up
imaging.
Mass Details
Primary Study
Additional Studies
1) >4cm;
For pre-op:
CT abdomen with
2) No history of
contrast*(CPT®74160) -MRI abdomen without and with
malignancy
contrast*
Comments:
 Most would consider biopsy/resection.
 PET can be considered for pre-operative study.
 MIBG if suspect pheochromocytoma
Continued next page . . .
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Page 30 of 73
AB-21.1 Adrenal Cortical Lesions Continued . . .
Imaging Decision Tree: Incidentally Discovered Adrenal Mass1,2,3,4
Mass Details
1) <4cm;
2) History malignancy
Primary Study
-CT abdomen
without contrast
(CPT®74150)
Additional Studies
-CT abdomen without and with*
(CPT®74170);OR
-MRI abdomen without contrast**
(CPT®74181); OR
-PET Scan
Comments:
 Biopsy/resection if suspicious imaging and can’t be determined benign.
 MIBG if suspect pheochromocytoma
 *Delayed imaging obtained to calculate washout
 **also appropriate for iodinated contrast allergy; chemical shift
Mass Details
1) >4cm;
2) History of malignancy
Comments:
None
Mass Details
1) Hormone secreting;
2) Cushing’s or Conn’s
Syndrome
Primary Study
-PET
Additional Studies
-Biopsy before or after PET
Primary Study
CT abdomen with
contrast bolus
arterial phase*
(CPT®74160)
Alternative Study(s)
NA
Comments:
*dexamethasone suppression, serum ACTH level, serum aldosterone/renin, and/or
virulizing hormone levels, and 24 hour urine for adrenal hormones confirm adrenal
cortical endocrine syndrome5
Mass Details
Primary Study
Alternative Study(s)
1) Hormone secreting;
-Any MRI abdomen
NA
2) Pheochromocytoma
requested*
Comments:
 Chemical shift MRI (CPT®74181) is the preferred imaging, since tumor lights
up brightly on T2 weighted images
 *hypertensive crises may be precipitated with bolus IV contrast
See next page for Normal Laboratory Values . . .
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AB-21.2 Normal Laboratory Values
Normal Values
Aldosterone
3-10 ng/dl (supine)
5-30 ng/dl (upright)
Cortisol
at 8am 250-850 nmol/L
at 4pm 110-390 nmol/L
at 10pm 50% of 8am value
AB-21.3 Adrenal Insufficiency
 CT or MRI is supported to determine the cause of primary adrenal insufficiency.
Imaging is necessary if testing has confirmed adrenalinsufficiency or
adrenomyeloneuropathy6,7.
Practice Notes
The majority of “incidentalomas” are benign adenomas. The risk of primary adrenal
carcinoma is as high as 5%. Metastases with history of malignancy are 25-75%. Routine
screening for endocrine function is recommended since 5%-23% will be hormone
secreting.
Resection or biopsy is often considered for mass lesions larger than 4 cm or hormonesecreting tumors should be resected.
Biopsy may be considered if pheochromocytoma is excluded.
Signs and symptoms of pheochromocytoma:
 Flushing spells and/or poorly controlled hypertension.
 Elevated plasma or urine metanephrines support the diagnosis of
pheochromocytoma with sensitivity for diagnosis at 99.7%.
If plasma metanephrines are not elevated, a 24-hour urine for catecholamine and
metanephrine levels should be obtained prior to considering advanced imaging.
If catecholamine and metanephrine levels are not elevated in a 24- hour urine test, then
no advanced imaging is indicated unless unexplained symptoms suggestive of
pheochromocytoma persist.
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References
1. Hamrahian AH, Ioachimescu AG, Remer EM, Motta-Ramirez G, et al. Clinical utility of noncontrast
computed tomography attenuation value (Hounsfield Units) to differentiate adrenal
adenomas/hyperplasias from nonadenomas: Cleveland Clinic Experience. Journal of Clinical
Endocrinology & Metabaolism, 2005 Feb;90(2):871-877.
2. Remer EM, Casalino DD, Bishoff JT, Coursey CA, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® incidentally discovered adrenal mass. American College of Radiology
(ACR); 2012.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/IncidentallyDiscoveredAdren
alMass.pdf, accessed June 10, 2013.
3. Song JH, Chaudry FS, Mayo-Smith WW. The incidental indeterminate adrenal mass on CT (> 10
H) in patients without cancer: is further imaging necessary? Follow-up of 321 consecutive
indeterminate adrenal masses. American Journal of Reontgenology, 2007, 189:1119-1123.
4. Song JH, Chaudry FS, Mayo-Smith WW. The incidental adrenal mass on CT: prevalence of adrenal
disease in 1,049 consecutive adrenal masses in patients with no known malignancy. American
Journal of Reontgenology, 2008 May;190:1163-1168.
5. Funder JW, Carey RM, Fardella C, Gomez-Sanchez CE, et al. Case Detection, Diagnosis, and
Treatment of Patients with Primary Aldosteronism: An Endocrine Society Clinical Practice
Guideline. Journal of Clinical Endocrinology and Metabolism, 2008 Sept;93(9):3266-3281.
6. Wallace I, Cunningham S, Lindsay J. The diagnosis and investigation of adrenalinsufficiency in
adults. Ann Clin Biochem. 2009 Sep;46(Pt 5):351-67.
7. Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003 May 31;361(9372):1881-93.
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AORTA
AB-22~Abdominal Aortic Aneurysm (AAA), Iliac Artery Aneurysm
(IAA), and Visceral Artery Aneurysms
Follow-Up of Known Aneurysms and Pre-Op Evaluation
AB-22.1 Abdominal Aortic Aneurysm (AAA)
Non-Obese Patient
 Ultrasound (CPT®76775) is the preferred initial imaging study to screen or surveil for
AAA or to evaluate a pulsatile abdominal mass.
Obese Patient
 CT abdomen with contrast(CPT®74160) can be substituted for US using the same
timeline as non-obese patient
Screening
 One-time screening recommendations for AAA (Ultrasound (CPT®76775))
o Men age 65 to 75 who have smoked
o Women and non-smokers – no routine screening
o Medicare covers a one-time AAA screening ultrasound (procedure code G0389) if
there is at least one of the following risk factors:
 Family history of AAA
 Patient is a male age 65 to 75 who has smoked at least 100 cigarettes in his
lifetime.
Surveillance
 Surveillance recommendations for AAA (Ultrasound (CPT®76775))
o 2.6-2.9cm once at 5 years
o 3.0-3.4cm once at 3 years
o 3.5-4.4cm annually
o 4.5-5.4 every 6 months
 >5.4 cm. or aortic diameter has increased in size by 0.7 cm in six months or at least 1
cm in a year may undergo more frequent monitoring and should be evaluated by a
Vascular Specialist.
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Additional Imaging
 CT of the abdomen and pelvis with contrast (CPT®74177), CT of the abdomen and
pelvis without and with contrast (CPT®74178), or CTA (CPT®74175 and
CPT®72191).
o Preoperative imaging if endovascular or open repair of AAA is being considered
o New onset of abdominal pain in a patient with a known AAA
Also see:
PVD-6~Aortic Disorders, Renal Vascular Disorders, and Visceral Artery Aneurysms in
the Peripheral Vascular Disease Imaging Guidelines.
Practice Note
There is insufficient evidence to support the use of advanced imaging to screen for
thoracic aortic aneurysm in patients with known abdominal aortic aneurysm.
AB-22.2 Iliac Artery Aneurysm (IAA)
 Evaluation of a suspected IAA should begin with ultrasound.
1. If ultrasound is equivocal, CT pelvis with contrast (CPT®72193) may be
performed.
2. Follow-up imaging studies can be performed annually
Additional Imaging
 CT of the abdomen and pelvis with contrast (CPT®74177), CT of the abdomen and
pelvis without and with contrast (CPT®74178), or CTA (CPT®74175 and
CPT®72191).
o Preoperative imaging if endovascular or open repair is being considered
Practice Notes
 Iliac artery aneurysms are most commonly associated with aortic aneurysms.
 Isolated IAA’s are rare.
 Approximately one third to one half of isolated IAA’s are bilateral at time of
presentation.
 The majority of patients are male and between 50 and 70 years old.
 The normal size of the iliac artery is <1cm.
 Aneurysm rupture usually occurs at a diameter of 5 cm or larger, whereas common
iliac aneurysms that are less than 3 cm in diameter almost never rupture.
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AB-22.4 Visceral Artery Aneurysm
Also see:
PVD-6~Aortic Disorders, Renal Vascular Disorders, and Visceral Artery Aneurysms in
the Peripheral Vascular Disease Imaging Guidelines
Reference
1. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease
(lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American
Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular
Angiography and Interventions, Society for Vascular Medicine and Biology, Society of
Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing
Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease):
endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National
Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society
Consensus; and Vascular Disease Foundation. Circulation, 2006, Mar 21;113 (11):e463-654.
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AORTA
AB-23~Abdominal Aortic Aneurysm (AAA) and Iliac Artery Aneurysm
(IAA)-Post Endovascular or Open Aortic Repair
AB-23.1 AAA, IAA, Post Endovascular or Open Aortic Repair
 Any one of the following studies can be used after aortic intervention:
o CT of the abdomen and/or pelvis with contrast (CPT®74177), or
o CT of the abdomen and/or pelvis without and with contrast (CPT®74178), or
o CTA of the abdomen and/or pelvis (CPT®74175 and CPT®72191), or
o MRA of the abdomen and/or pelvis (CPT®74185 and CPT®72198)
 Open Aortic Repair - every 3 years to screen for aneurysms in the remaining aorta1
 Endovascular (Stent) Aortic Repair -1 month, 6 months, and 12 months following
repair, then every year2
o An additional study at 3 months can be performed if there was evidence of
endoleak on the 1 month study.
 Any of the following studies can be used after endovascular iliac repair (stent):
o CT pelvis (CPT®72193 or CPT®72194), or
o CTA pelvis (CPT®72191), or
o MRA pelvis (CPT®72198)
 Endovascular (Stent) Iliac Repair- one week, one month, 3 months, and 6 months after
endovascular treatment, and then every 6 months thereafter.3
References
1. Upchurch GR, Schaub TA. Abdominal aortic aneurysm. American Family Physician,2006 Apr
1;73(7):1198-1204.
2. Back MR. Surveillance after endovascular abdominal aortic aneurysm repair. Perspectives in
vascular surgery and endovascular therapy, 2007, 19: 395-400.
3. Sakamoto I, Sueyoshi E, Hazama S, Makino K, et al. Endovascular treatment of iliac artery
aneurysms. Radiographics October 2005 25:S213-S227.
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AORTA
AB-24~AORTIC DISSECTION and IMAGING for OTHER AORTIC
CONDITIONS
AB-24.1 Aortic Dissection and other Aortic Conditions
 Any one of the following studies can be used if acute dissection is suspected:
o CT of the chest and/or abdomen and/or pelvis with or without and with contrast
(CPT®74177), or
o CTA of the chest and/or abdomen and/or pelvis (CPT®71275, CPT®74175 and
CPT®72191), or
o MRA of the chest and/or abdomen and/or pelvis (CPT®71555, CPT®74185 and
CPT®72198)
o See CH-32~Thoracic Aortic in the Chest Imaging Guidelines
AB-24.2 Imaging for Other Aortic Conditions
 Chest CTA (CPT®71275) prior to minimally invasive or robotic surgery.
(See also: CD-1.10 in the Cardiac Imaging Guidelines.)
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Page 38 of 73
BOWEL (ALPHABETICAL ORDER)
For diverticulitis, see: AB~7
For mesenteric/colonic ischemia, see: AB~9.
AB-25~BOWEL OBSTRUCTION
AB-25.1 Bowel Obstruction
 Plain x-rays of the abdomen (obstructive series) should be obtained as the initial study
in patients with suspected bowel obstruction.
 CT of the abdomen and pelvis with contrast (CPT®74177) may be used for:
o Plain x-rays that are abnormal or equivocal
o High index of suspicion for bowel obstruction (abdominal pain, vomiting,
constipation, abdominal distention, failure to pass flatus), especially in patients
with prior history of abdominal surgery, history of malignancy, or patients with
current hernias.1
Reference
1. Small WC, Rose TA Jr, Rosen MP, Blake MA, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® suspected small-bowel obstruction. American College of Radiology
(ACR); 2010. http://www.acr.org/~/media/EA869AFF013A444C8F889A303F188D34.pdf accessed
June 10, 2013.
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AB-26~Diarrhea, Constipation, and Irritable Bowel
AB-26.1 Diarrhea/Constipation
 CT scan of abdomen and pelvis with contrast (CPT®74177) can be used if:
o Diarrhea and any of the following: fever, weight loss, abnormal physical
examination findings, fecal incontinence, GI bleeding, or abnormal labs including
stool analysis
o Constipation and any of the following family history of inflammatory bowel
disease or cancer, onset of constipation after age 50, acute onset of constipation in
the elderly, GI bleeding, fever, substantial pain, vomiting, weight loss, rectal pain,
abnormal lab studies, or abnormal physical examination findings
o Diarrhea or constipation which has failed conservative 2 weeks of conservative
management
 MRI Defecography can be considered only if ordered for preoperative evaluation for
the planning of complex pelvic reconstruction.
AB-26.2 Bloating and/or Irritable Bowel Syndrome
 Advanced imaging is not needed for suspected or known Irritable Bowel Syndrome
which is a diagnosis of exclusion with the following symptoms:
o Abdominal pain
o Change in frequency (diarrhea, constipation or both) and form of stool
o Relief of symptoms with defecation
References
1. O’Connor OJ, McSweeney SE, McWiliams S, et al. (2012). Role of radiologic imaging in irritable
bowel syndrome: Evidence-based review. Radiology, 262(2), 485-494.
2. Holten KB, Wetherington A, Bankston L. Diagnosing the patient with abdominal pain and altered
bowel habits: Is it Irritable Bowel Syndrome? Am Fam Physician 2003 May; 67(10):2157-2162
3. Serper M. Irritable bowel syndrome: evidence-based evaluation and management. Patient Care
Online, July 16, 2007, http://www.patientcareonline.com.
4. El-Baba MF. Irritable Bowel Syndrome. eMedicine, Updated January 13, 2010,
http://emedicine.medscape.com/article/930844-overview.
5. American Gastroenterological Association. AGA medical position statement: Guidelines on
constipation. Gastroenterol 2000;119:1761-1778.
6. Schiller LR. Chronic diarrhea. Gastroenterol 2004;127:287-293.
7. Arce D A, Ermocilla C A, Costa H. Evaluation of constipation. Am Fam Physician. 2002;65:2283–
2290.
8. Cash, BD, Chang L, Sabesin SM, Vitat P. Update on the management of adults with chronic
idiopathic constipation. J Fam Practice 2007 June;56(6 Suppl):S13-S20\
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9. Cortes E, Reid WMN, Singh K, Berger L. Clinical examination and dynamic magnetic resonance
imaging in vaginal vault prolapse. Obstet Gynecol 2004; 103:41-46.
10. Roos JE, Weishaupt D, Wildermuth S, Willmann JK, et al. Experience of 4 Years with Open MR
Defecography: Pictorial Review of Anorectal Anatomy and Disease. Radiographics 2002;22:817832
AB-27~GI BLEEDING
AB-27.1 GI Bleeding
 Abdomen CTA with and without contrast (CPT®74175) or CT of the abdomen and
pelvis with contrast (CPT®74177) can be considered if any of the following is
accompanied with GI bleeding1,2:
o Severe abdominal pain; or
o Hemodynamic instability; or
o Endoscopy is contraindicated or negative.
References
1. Laing CJ, Tobias T, Rosenblum DI, Banker WL, et al. Acute gastrointestinal bleeding: emerging
role of multidetector CT angiography and review of current imaging Techniques. Radiographics,
2007, 27, 1055-1070.
2. American Gastroenterological Association medical position statement: Evaluation and management
of occult and obscure gastrointestinal bleeding. Gastroenterology, 2000, 118(1), 197-200.
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AB-28~INFLAMMATORY BOWEL DISEASE
Rule Out Crohn’s Disease or Ulcerative Colitis
AB-28.1 IBD rule out Crohn’s Disease or Ulcerative Colitis
 Suspected or Known Crohn’s Disease or Ulcerative Colitis
o CT of the abdomen and pelvis with contrast (CPT®74177), CT enteroclysis
(CPT®74176 or CPT®74177) or CT enterography (CPT®74177) if diagnosis is
otherwise inconclusive or suspected complications, including abscess, perforation,
fistula, or obstruction.
o MRI Enterography (CPT®74183 and CPT®72197) may be performed, especially in
young patients to avoid radiation, to monitor response to immune-modulatory
agents, and to differentiate acute phase disease from remission.1
 Rectal/Peri-Rectal involvement
o Endoscopic ultrasound, rectal ultrasound or MRI (CPT®72197)2,3
 SPECT,PET and PET/CT Enterography are considered investigational4
References
1. Lichtenstein GR, Hanauer SB, Sandborn WJ, and The Practice Parameters Committee of the
American College of Gastroenterology. ACG Practice Guidelines: Management of Crohn’s Disease
in Adults. American Journal of Gastroenterology, 2009, January.
2. Hara AK, Leighton JA, Heigh RI, Shama VK, et al. Crohn disease of the small bowel: preliminary
comparison among CT enterography, capsule endoscopy, small-bowel follow-through, and
ileoscopy. Radiology, 2006 , 238:128-134.
3. Lin MF, Narra V. Developing role of magnetic resonance imaging in Crohn's disease. Current
Opinion in Gastroenterology, 2008, 24(2):135-140.
4. Fidler JL, Rosen MP, Blake MA, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® Crohn disease. American College of Radiology (ACR); 2011.
http://www.acr.org/~/media/D407B89280354E86B0D90F9177B195DE.pdf, accessed June 10,
2013.
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AB-29~CELIAC DISEASE (SPRUE)
AB-29.1 Celiac Disease
 Diagnosis is made by blood testing1:
o Anti-tissue transglutaminase antibody [anti-tTG], anti-endomysium antibody
(EMA), total IgA count, CBC to detect anemia, ESR, C-reactive protein, complete
metabolic panel, vitamin D, E, B12 levels
 Endoscopy and biopsy of the small bowel is performed to confirm the diagnosis if the
tTG and EM9A tests are positive.
 CT abdomen and pelvis with contrast (CPT®74177) or CT enteroclysis (CPT®74176
or CPT®74177) for:
o For confirmed celiac disease (as this may be disguised intestinal lymphoma and
other bowel cancers);
o New or continued weight loss, diarrhea, abdominal distention, or anemia, despite
adherence to a gluten free diet.
Practice Notes
Celiac is an autoimmune disease in which the villi of the small intestine are damaged
from eating gluten (found in wheat, barley, and rye).
Reference
1. Rubio-Tapia A, Hill ID, Kelly C, Calderwood AH, Murray JA. ACG Clinical Guidelines: diagnosis
and management of celiac disease. American Journal of Gastroenterology, 2013.
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AB-30~CT COLONOGRAPHY (CTC)
AB-30.1 CTC
Certain payers consider CTC investigational and their coverage policies will take
precedence over MedSolutions’ guidelines.
 Screening CTC (CPT®74263) for colorectal cancer1,2:
o Every 5 years in average-risk individuals ages 50 to 75 (average risk is defined as
no history of adenoma and inflammatory bowel disease and negative for first
degree family history of colorectal cancer)
 This coverage may vary according to health plan/payor
 Diagnostic CTC (CPT®74261, without contrast or CPT®74262, with contrast,
including noncontrast images if performed) can be used in:
o Failed conventional colonoscopy (e.g. due to a known colonic lesion, structural
abnormality or technical difficulty)
o Conventional colonoscopy is medically contraindicated. Contraindications may
include4:
 Coagulopathy
 Intolerance to sedation
 Elderly greater than or equal to 80 years of age
References
1. U.S. Preventive Services Task Force. Screening for colorectal cancer: U.S. Preventive Services Task
Force Recommendation Statement. Annals of Internal Medicine, 2008; 149: 627-637.
2. Qaseem A, Denberg TD, Hopkins RH, Humphrey LL, et al. Screening for colorectal cancer: A
guidance statement from the American College of Physicians. Annals of Internal Medicine, 2012;
156:378-386.
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LIVER
AB-31~CIRRHOSIS and LIVER SCREENING
for Hepatocellular Carcinoma (HCC)
AB-31.1 Cirrhosis and Liver Screening for HCC
 Ultrasound every 6 months 1,2 for patients at high risk for developing hepatocellular
carcinoma (HCC)
o High-risk = Hepatitis B or C, non-hepatitis cirrhosis, or genetic hemochromatosis
o First ultrasound can be CPT®76700 or CPT®76705
o Follow-up ultrasounds should be CPT®76705
 MRI abdomen without and with contrast (CPT®74183), or CT abdomen without and
with contrast (CPT®74170), can be performed:
o Based on AB-34~Liver Lesion Characterization,
o Liver lesion identified (prior to biopsy)
o AFP greater than 20
o Continue CT or MRI lesion surveillance at 3 months, and then return to ultrasound
every 6 months
 Liver Transplant:
o See AB-48.1 Liver Transplant
Practice Note
Individuals with hepatitis and cirrhosis are at increased risk for developing hepatocellular
carcinoma (HCC). Most studies have shown no benefit to HCC screening and most major
US Associations either do not have guidelines (USPSTF, NCCN, & ACS) or recommend
against screening (NCI); however, the American Association for the Study of Liver
Diseases (AASLD) and EASL recommend ultrasound screening every 6 months for high
risk. One study3 demonstrated that ultrasound screening among high risk populations can
reduce mortality from HCC by one-third. This study has become the basis for most US
screening programs. No studies have demonstrated that CT or MRI improves screening
outcomes.
References
1. Bruix J, Sherman M. AASLD Practice Guideline: Management of hepatocellular carcinoma, an
update. Hepatology, 2011, 53(3), 1-35.
2. Parikh S, Hyman D. Hepatocellular Cancer: A Guide for the Internist. The American Journal of
Medicine, 2007, 120, 194-202.
3. Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular
carcinoma. Journal of Cancer Research and Clinical Oncology, 2004, 130(7), 417-22.
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4. Manelli, L, Rosenkrantz AB. Focal lesions in the cirrhotic liver. Applied Radiology.
http://www.appliedradiology.com/Issues/2013/10/Articles/AR_0-13_Mannelli/Focal-lesions-in-thecirrhotic-liver.aspx#.Ulhyu-dkrE4.email. Accessed October 14, 2013.
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LIVER
AB-32~MR CHOLANGIOPANCREATOGRAPHY (MRCP)
MRCP is an alternative to endoscopic retrograde cholangiopancreatography (ERCP) for
evaluating the biliary system and pancreatic ducts. It should not be used if there is a high
probability of biliary obstruction based on CT or endoscopic ultrasound (EUS) and if
therapeutic intervention will likely be needed. In this situation ERCP should be used.1
AB-32.1 MRCP
 Rule out pathology in the biliary system or pancreatic duct when ERCP or other
invasive interventional procedure is being considered but the pre-procedure suspicion
of the need for therapeutic intervention is not high enough to warrant performing
ERCP initially.
o Examples include:
 Suspected or known gallstone pancreatitis
 Suspected biliary pain with low probability of common duct stone
 Pancreatic pseudocyst (for preoperative cyst drainage and/or pancreatic trauma
with suspected duct injury)
 Pancreatic trauma
 Recurrent acute pancreatitis with no known cause
 Preoperative planning
 Evaluation of congenital anomaly of pancreaticobiliary tract
 Altered biliary anatomy that precludes ERCP (e.g. post-surgical distorted anatomy)
 Failed ERCP in a patient who needs further investigation
 Evaluation of pancreaticobiliary anatomy proximal to a biliary obstruction that cannot
be opened by ERCP
 ERCP is indicated but is not available, is contraindicated, or is expected to be difficult
o Examples include coagulopathy, severe cardiopulmonary disease, allergy to
iodinated contrast, distorted anatomy, pregnant patient
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Coding Notes
 Code assignment for MRCP
o There is no CPT® code that specifically describes MRCP.
o Generally, an MRCP includes a standard abdominal MRI along with 3D
cholangiographic renderings.
o To report an MRCP, one code from the set: CPT®74181- CPT®74183 should be
selected along with a code for 3D rendering (either CPT®76376 or
CPT®76377). The specific MRI code should be selected based on whether or
not intravenous contrast was administered.
o Reporting/billing a second MRI code, to represent the “MRCP portion” of the
study is not supported.
o There is a Level II HCPCS code for MRCP, S8037 (Magnetic resonance
cholangiopancreatography).
 S8037 (and any other code beginning with the letter “S”) is not payable by
Medicare. Some other payors may accept this code.
 MRCP should be reported with one CPT® for MRI of the abdomen (and one
code for 3D rendering) or with HCPCS code S8037, but not both.
References
1. American College of Radiology. ACR practice guideline for the performance of magnetic resonance
imaging (MRI) of the abdomen. Reston (VA): American College of Radiology (ACR); 2010
2. Kaltenthaler EC, Walters SJ, Chilcott J, Blakeborough A et al. MRCP compared to diagnostic ERCP
for diagnosis when biliary obstruction is suspected: a systematic review. BMC Medical Imaging,
2006, 6:9.
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LIVER
AB-33~JAUNDICE
AB-33.1 Jaundice
 Ultrasound1 (CPT®76700 or CPT®76705) is the preferred initial imaging study to
visualize the biliary ductal system when pain is present. Ultrasound often
demonstrates the level and cause of any obstruction.
 Abdomen CT2 without or with contrast (CPT®74170) or Abdomen CT with contrast
should be considered in the following scenarios:
o If non-diagnostic or equivocal ultrasound
 e.g., large amounts of intestinal gas
o Patient is obese
o Painless jaundice
o Acute abdominal pain and one of following: fever, previous biliary surgery, or
known cholelithiasis.
o If there is high pretest probability of obstruction due to malignancy1
 MR cholangiopancreatography (MRCP) (See: AB-32~MRCP) may be used to assess
the extent and cause of intrahepatic bile duct obstruction:
o Suggested by either ultrasound or CT if further characterization is warranted.
o Contraindications to the use of IV contrast for CT imaging.
Practice Notes
Caused by an inherited gene mutation, Gilbert’s Syndrome is a liver condition in which
the liver doesn't properly process a substance called bilirubin. It is often detected
incidentally when a blood test shows elevated bilirubin levels.
Normal Values:
o Bilirubin (total) 0.2-1.0 mg/dl
o Bilirubin (conjugated) 0-0.2 mg/dl
References
1. Lalani T, Couto CA, Rosen MP, Baker ME, et al. ACR Appropriateness Criteria® jaundice.
American College of Radiology (ACR), 2012.
http://www.acr.org/~/media/553B1108216749ECADE662580FEBF1F0.pdf, accessed June 11,
2013.
2. Saini S. Imaging of hepatobiliary tract. N Engl J Med 1997;336:1889–1894.
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LIVER
AB-34~LIVER LESION CHARACTERIZATION
AB-34.1 Liver Lesion Characterization
 Ultrasound1 (CPT®76700 or CPT®76705) should be considered:
o For suspected hepatomegaly
o To evaluate for biliary disease or isolated liver lesion in Nonalcoholic Fatty Liver
Disease (NFLD)2
o For suspected simple cyst
 MRI abdomen without and with contrast (CPT®74183), or CT abdomen without and
with contrast (CPT®74170):
o For any indeterminate liver lesion identified on any other imaging, including
suspected hemangioma, hepatic adenoma, focal nodular hyperplasia3 (FNH) and a
lesion identified in cirrhotic liver
o Suspected metastases can also undergo, in lieu of one of the above two studies, CT
abdomen with contrast (CPT®74160) since these tend to be hypovascular
o Percutaneous liver biopsy is to be considered if imaging is atypical or
inconclusive4
o Diagnosis for HCC is done with imaging, biopsy is not needed for diagnosis5
 Further evaluation
o MRI abdomen without and with contrast (CPT®74183) can be considered if an
initially performed CT abdomen without and with contrast (CPT®74170) is
equivocal
o MRA abdomen (CPT®74185) or CTA abdomen (CPT®74175) for preoperative
study in patients with large hemangiomas or adenomas considered for resection
o CT or MRI can be repeated after 3 months, then every 6 months for 3 years if liver
lesion not biopsied or resected.
o No further diagnostic imaging is needed if:
 Primary or metastatic malignancy, unless biopsy assisted or PET for staging
 Simple cyst or hemangioma
 Benign on biopsy
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References
1. Lalani T, Rosen MP, Blake MA, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® liver lesion -- initial characterization. American College of Radiology
(ACR), 2010. http://www.acr.org/~/media/4C9D1E9471784D92A413A120AB140401.pdf, accessed
June 11, 2013.
2. Bayard M, Holt J, Boroughs E. Nonalcoholic Fatty Liver Disease. American Family Physician,
2006, 73(11), 1961-1968.
3. Ferlicot S, Kobeiter H, Tran Van Nhieu J, Cherqui D, et al. MRI of Atypical Focal Nodular
Hyperplasia of the Liver: Radiology–Pathology Correlation. American Journal of Roentgenology,
2004, 182:1227-1231.
4. Sanyal AJ. AGA technical review on nonalcoholic fatty liver disease. Gastroenterology 2002,
123(5):1705-1725
5. Bruix J, Sherman M. AASLD Practice Guideline: Management of hepatocellular carcinoma, an
update. Hepatology, 2011, 53(3), 1-35.
6. Manelli, L, Rosenkrantz AB. Focal lesions in the cirrhotic liver. Applied Radiology.
http://www.appliedradiology.com/Issues/2013/10/Articles/AR_0-13_Mannelli/Focal-lesions-in-thecirrhotic-liver.aspx#.Ulhyu-dkrE4.email. Accessed October 14, 2013.
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LIVER
AB-35~ELEVATED LIVER FUNCTION (LFT) LEVELS
AB-35.1 Elevated Liver Function Levels
 CT1,2 of the abdomen without and with contrast (CPT®74170), CT of the abdomen
with contrast (CPT®74160) or MRI of the abdomen without and with contrast
(CPT®74183) for:
o Elevation LFTs of AST and/or ALT less than two times normal if:
 Persistent elevation of AST or ALT after 3 weeks, with discontinuation of lipid
lowering medications (statins, niacin, sulfa, rifampin, tetracycline, estrogen,
acetaminophen, etc.) if applicable
 Any abnormality or suspicion on Ultrasound (CPT®76705)
o Elevation of LFT’s of AST and/or ALT greater than or equal to two times normal
o Known cancer and suspected liver metastases
o Elevated alpha-fetoprotein (AFP) levels
 For Jaundice, see: AB-33~Jaundice
 MRCP can be considered if biliary dilatation is seen on ultrasound or CT
o (See: AB-32~MRCP for coding guidelines for MRCP)
Practice Notes
The enzymes included in this category are AST, ALT, alkaline phosphatase, GGT, and
bilirubin.
References
1. O’Shea RS, Dasarathy S, McCullough AJ. ACG practice guidelines: alcoholic liver disease.
American Journal of Gastroenterology, 2010, 105: 14-32.
2. Sahani DV, Kalva SP.Imaging the Liver. The Oncologist, 2004,9, 385-397.
3. Saini S. Imaging of hepatobiliary tract. N Engl J Med 1997;336:1889–1894
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LIVER
AB-36~RULE OUT LIVER METASTASIS
See:
ONC-5~Metastatic Cancer and Carcinomas of Unknown Primary Site
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PANCREAS
AB-37~PANCREATIC LESION
AB-37.1 Pancreatic Lesion
Screening studies for pancreatic cancer can be considered in those who are considered
high risk in the following guideline: ONC-14~Pancreatic Cancer in the Oncology
Imaging Guidelines
AB-37.2 Pancreatic Lesion (Incidental Pancreatic Cyst)
 Abdominal CT (CPT®74170) preferably, thin slice or MRI with and without contrast
(CPT®74183) for the following:1,2
o <1cm in size, may be performed annually
o 1-2 cm, may be performed every 6-12 months
o Greater than 2 cm, may be performed every 3-6 months
 Evaluation of pancreatic cystic lesions by endoscopic ultrasound (EUS) and MRCP1,2
for the following:
o Those greater than 3 cm or with other concerning features (mural nodules,
dilated duct, pain, positive cytology, jaundice, worsening diabetes, etc) should
be considered for resection.
o (See: AB-32~MRCP for coding guidelines for MRCP).
AB-37.3 Pancreatic Lesion (Incidental Pancreatic Mass or Suspected Metastatic
Disease to Pancreas)
 CT abdomen with contrast with dual phase imaging (CPT®74170), or CT abdomen
without and with contrast (CPT®74170) (dedicated pancreatic protocol) since the
majority of pancreatic tumors will enhance following IV contrast).2
References
1. Khalid A, Brugge W. ACG practice guidelines for the diagnosis and management of neoplastic
pancreatic cysts. The American Journal of Gastroenterology, 2007, 102 (10), 2339-49.
2. Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, et al. Managing incidental findings on
abdominal CT: white paper of the ACR incidental findings committee. Journal of the American
College of Radiology, 2010, 7(10), 754-773.
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PANCREAS
AB-38~PANCREATIC PSEUDOCYSTS
AB-38.1 Pancreatic Pseudocysts
 CT of the abdomen with contrast (CPT®74160), or without and with contrast
(CPT®74170),1,2 or abdominal MRI with and without contrast
o Minimal symptoms - every two weeks, up to six weeks total. Thereafter, every 4
weeks.
o Anytime symptoms worsen, including development of ascites or pleural effusion,
increasing serum amylase, or if drainage of the cyst is planned.
 MRCP for preoperative planning cyst drainage:
o (See: AB-32~MRCP for coding guidelines for MRCP)
 MRCP for pancreatic trauma with suspected duct injury or pseudocyst
Practice Notes
Endoscopic ultrasound has increasingly become an important imaging modality in
evaluating pseudocysts.2
References
1. Doherty GM, Way LW. Chapter 26. Pancreas. In: Doherty GM, ed. CURRENT Diagnosis &
Treatment: Surgery. 13th ed. New York: McGraw-Hill; 2010.
http://www.accessmedicine.com/content.aspx?aID=5217299. Accessed June 12, 2013.
2. Federle MP and Anne VS. Pancreatic pseudocyst. In Federle MP, Jeffrey RB, Desser TS, et. al.
(Eds.). Diagnostic Imaging Abdomen,1st Ed. Salt Lake City, Amirsys and Elsevier Publishers, 2004,
pp. II;3;24-25
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PANCREAS
AB-39~PANCREATITIS
AB-39.1 Pancreatitis
 Ultrasound2 (CPT®76700 or CPT®76705) is the first study to evaluate:
o Mild and uncomplicated symptoms of epigastric pain described as uncomfortable
without guarding to rule out gallstone disease
o If ultrasound suggests uncomplicated pancreatitis, then advanced imaging is not
necessary. For complicated pancreatitis, see below.
 CT abdomen2 with contrast (CPT®74160), without contrast (CPT®74150) or without
and with contrast (CPT®74170)
o Suspected complications including peripancreatic effusions, pseudocysts, abscess,
and pancreatic necrosis
o Lipase and/or amylase greater than or equal to three times the upper limit of
normal and any one of the following:
 Fever (101 degrees or greater)
 Elevated WBC (10,000 or greater)
 Mass
 No improvement with medical therapy
o Suspected pancreatitis and ultrasound findings do not explain symptoms
(gallstones, common duct, etc)
o Plain abdominal x-ray (KUB) and ultrasound (CPT®76700 or CPT®76705) are not
characteristic and diagnostic in known chronic pancreatitis
 MRI without and with contrast2 (CPT®74183) is considered if:
o CT is contraindicated and CT indications met or equivocal
 MR cholangiopancreatography1,2 can be considered if:
o Suspected gallstone pancreatitis to screen for those patients who would benefit
from ERCP
o Recurrent, acute pancreatitis with no known cause
o Plain abdominal x-ray (KUB) and ultrasound (CPT®76700 or CPT®76705) are not
characteristic and diagnostic in known chronic pancreatitis and findings will affect
management decisions
o MRCP—See: AB-32~MRCP for coding guidelines for MRCP
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Practice Notes
The diagnosis of acute pancreatitis is often made by fulfilling two of the following three
(3) conditions1:
1. Typical pain (acute onset of epigastric pain radiating to the back that is persistent
without relief, frequently associated with nausea and vomiting, and associated with
severe epigastric tenderness and/or guarding, and/or fever)
2. Lipase and/or amylase greater than or equal to three times the upper limit of
normal
3. Typical characteristics of pancreatitis on CT abdomen
Chronic pancreatitis that is suspected as evidenced by recurrent characteristic pancreatic
pain, symptoms of maldigestion/malabsorption that improve with digestive enzymes,
does not require the use of advanced imaging1
For known Chronic Pancreatitis Including Hereditary Pancreatitis, there is no
evidence-based data supporting screening1
Acute pancreatitis is divided clinically into non-severe (previously called mild) and
severe pancreatitis.3
o Non-severe pancreatitis represents interstitial edematous pancreatitis, and severe
pancreatitis manifests as necrotizing pancreatitis or as pancreatitis associated with
organ failure.
o Serum enzyme levels do not correlate with the severity of the disease
o Clinical scoring systems and imaging tests have been advocated to classify
individual patients in terms of severity.
o The diagnosis may be overlooked in the absence of typical enzyme elevation; in
some patients, acute pancreatitis may be present in the absence of enzyme
abnormalities
References
1. Carroll JK, Herrick B, Gipson T, Lee SP. Acute Pancreatitis: Diagnosis, Prognosis, and Treatment.
American Family Physician, 2007, 15;75(10):1513-1520.
2. Macari M, Rosen MP, Blake MA, Baker ME, et al. Expert Panel on Gastrointestinal Imaging. ACR
Appropriateness Criteria® acute pancreatitis, American College of Radiology (ACR); 2010.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcutePancreatitis.pdf
3. Banks PA, Conwell DL, Toskes PP. The management of acute and chronic pancreatitis.
Gastroenterolgy & Hepatology, 2010, 6(2 Suppl. 5), 1-16.
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SPLEEN
AB-40~SPLEEN
AB-40.1 Spleen
 Ultrasound1 (CPT®76700 or CPT®76705) is considered the initial imaging modality
for:
o Incidental cystic splenic lesion seen on a non-abdominal imaging study
 Splenic cysts < 5 cm in diameter should be followed yearly or until new
symptoms present.
 Splenic cysts 5 cm or greater should be referred for surgical evaluation.
o Splenomegaly
 CT2 abdomen without and with contrast (CPT®74170) or CT abdomen with contrast
should be considered when:
o Ultrasound is indeterminate or shows an abnormality
o Incidental non-cystic splenic lesion is seen on a non-abdominal imaging study
o Pre-operative for splenectomy
 MRI2 abdomen without and with contrast (CPT®74183) should be considered when:
o CT is indeterminate or IV contraindicated
o Pregnant women with indeterminate or abnormality ultrasound
AB-40.2 Trauma - Spleen
 Ultrasound or CT3,4,5 of the abdomen and pelvis without and with contrast
(CPT®74178) or with contrast are indicated in patients with blunt abdominal trauma
with suspected splenic rupture or in patients with penetrating trauma to the left upper
quadrant. (See AB-15~Blunt Abdominal Trauma)
Practice Notes
Splenomegaly is usually the result of systemic disease, and diagnostic studies are directed
toward identifying the causative disease. Complete blood count with differential, LFT’s,
and peripheral blood smear examination are often performed prior to considering
advanced imaging. There is no evidence-based data to support performing serial CT or
MRI to follow patients with incidental splenic lesions.
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References
1. Saboo SS, Krajewski KM, O’Regan KN, Giardino A et al. Spleen in haematological malignancies:
spectrum of imaging findings. British Journal of Radiology , 2012; 85: 81-92 2012
2. Benter T, Klühs L, Teichgräber U. Sonography of the spleen. J Ultrasound Med., 2011; 30:1281-93.
3. Killeen KL, Shanmuganathan K, Boyd-Kranis R, et al. CT findings after embolization for blunt
splenic trauma. J Vasc Interv Radiol. Feb 2001;12(2):209-14.
4. Naulet P, Wassel J, Gervaise A, Blum A. Evaluation of the value of abdominopelvic acquisition
without contrast injection when performing a whole body CT scan in a patient who may have
multiple trauma. Diagn Interv Imaging. Apr 2013;94(4):410-7.
5. Boscak AR, Shanmuganathan K, Mirvis SE, Fleiter TR, Miller LA, Sliker CW, et al. Optimizing
trauma multidetector CT protocol for blunt splenic injury: need for arterial and portal venous phase
scans. Radiology. Jul 2013;268(1):79-88.
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SPECIFIC ABDOMINAL ORGANS – STRUCTURES
RENAL
AB-41~INDETERMINATE RENAL LESION
For acute flank pain, rule out renal stone, see: AB-5~Flank Pain
AB-41.1 Indeterminate Renal Lesion
Newly Discovered Renal Mass (indeterminate by the initial test)
Mass
Size
For
Any
Size
Initial Imaging
(step 1)
-Ultrasound (CPT®76770
or CPT®76775); or
-CT abdomen without
and with contrast
(CPT®74170)
Secondary Imaging
(step 2)
No further imaging if:
 Simple cyst or other benign
lesion (e.g. Bosniak 1 or 2
,angiomyolipoma without
calcifications); or
 Biopsy makes the definitive
diagnosis of angiomyolipoma,
metanephric adenoma, or focal
infection
Otherwise, imaging as follows:
-CT of the abdomen without and
with contrast (CPT®74170); or
- MRI of the abdomen without and
with contract (CPT®74183)
Tertiary Imaging or Biopsy
(step 3)
No further imaging if:
 Benign on CT/MRI (e.g.
Bosniak 1 or 2, or
angiomyolipoma without
calcifications) or
 Biopsy diagnosis of
angiomyolipoma or focal
infection
Follow-up imaging with
original diagnostic modality
(US, CT or MRI) 6 to 12
months, then annually for 5
years if:
 Indeterminate on either
CT/MRI or biopsy or
 Biopsy nonmalignant
Continued on next page . . .
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Practice Notes
The most common renal mass is a cyst. The Bosniak Classification may be helpful to
evaluate renal cysts. It relates CT scan renal cyst characteristics and their relationship
with malignancy and need for follow-up:
Bosniak
Class
Bosniak 1
Bosniak 2
Bosniak 2F
Characteristic
Simple cyst, anechoic, imperceptible wall, rounded
Minimally complex, single thin (< 1mm) septations,
thin Ca++; non-enhancing
high-attenuation renal lesions of less than 3 cm are
also included in this category; these lesions are
generally well marginated.
Minimally complex.
• Increased number of septa, minimally thickened or
enhancing septa or wall
• Thick Ca++,
• Hyperdense cyst that is:
> 3 cm diameter, mostly intrarenal (less than 25% of
wall visible); no
enhancement
Bosniak 3
Indeterminate, thick or multiple septations,
mural nodule, hyperdense on CT (see 2F)
Bosniak 4
Clearly malignant, solid mass with cystic spaces
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Work-Up
%
Malignant
Nil
~0
Nil
~0
Ultrasound /
CT follow up
~5
Partial
nephrectomy
or RF
ablation,
in elderly /
poor surgical
risk
Partial/total
nephrectomy
Page 61 of 73
~50
>80
References
1. Israel GM, Casalino DD, Remer EM, Arellano RS, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® indeterminate renal masses. American College of Radiology (ACR); 2010.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/IndeterminateRenalMasses.pd
2. Inderbir S, Aron M, Gervais DA, Jewett MAS. Small renal mass. New England Journal of Medicine,
2010; 362:624-634.
3. Siegel CL, McFarland EG, Brink JA, Fisher AJ, Humphrey P, Heiken JP. CT of cystic renal masses:
analysis of diagnostic performance and interobserver variation. AJR 1997; 169(3):813-818.
4. Israel GM, Bosniak MA. How I do it: Evaluating renal masses. Radiology, 2005, 236, 441-450.
5. Curry NS, Cochran ST, Bissada NK. Cystic renal masses: Accurate Bosniak classification requires
adequate renal CT. American Journal of Roentgenology, 2000, 175, 339-342.
6. Higgins JC, Fitzgerald JM. Evaluation of incidental renal and adrenal masses. Am Fam Physician
2001;63:288–294, 299.
7. Gill IS, Aron M, Gervais DA, Jewett MAS. Small Renal Mass. N Engl J Med 2010;362:624-634
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RENAL
AB-42~RENAL FAILURE
AB-42.1 Renal Failure
 Ultrasound (CPT®76770 or CPT®76775) of the kidney and bladder, preferably with
Doppler, is the preferred imaging study for in the evaluation of acute or chronic renal
failure1
 MRA abdomen (CPT®74185) can be utilized when suspected1:
o Renal vein/caval thrombosis
o Renal artery stenosis as cause of renal failure
 CT abdomen without contrast (CPT®74150) is not needed except to rule out ureteral
obstruction or retroperitoneal mass1
References
1. Papnicolaou N, Francis IR, Casalino DD, Arellano RS, et al. Expert Panel on Urologic Imaging.
ACR Appropriateness Criteria® renal failure. American College of Radiology (ACR); 2008.
http://www.acr.org/~/media/CFBE883C503C45E982D4B722DE80230B.pdf Accessed June 17,
2013.
2. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification. 2012. American Journal of Kidney Disease, 2002, 39,
S1-S266.
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RENAL
AB-43~RENOVASCULAR HYPERTENSION
AB-43.1 Renovascular Hypertension
 MRA (CPT®74185) or CTA (CPT®74175) of the abdomen if1:
o Resistant to three blood pressure medications and two serial blood pressure
measurements (>140/90 without history of diabetes or renal disease or >130/80
with diabetes or renal disease)
 Home blood pressure measurements thwarting “white coat syndrome” and other
secondary causes may improve accuracy.2
o Anyone under 40 years old with hypertension, to exclude fibromuscular dysplasia
of the renal arteries.
o Sudden onset of significant hypertension (generally >160/100) or flash pulmonary
edema
o Women who develop hypertension (≥140/90) within the first 20 weeks of
pregnancy, if the hypertension persists >12 weeks post-partum
o Previously stable hypertension, with worsening hypertension or worsening renal
function/increasing creatinine (especially after the administration of an ACE
inhibitor or with angiotensin receptor blocking agent).
o Unexplained atrophic kidney or discrepancy in size between kidneys of greater
than 1.5 cm
 US kidney retroperitoneal (CPT®76775) with Doppler can be considered if expertise
is available
References
1. Harvin HJ, Casalino DD, Remer EM, Bishoff JT, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® renovascular hypertension. American College of Radiology (ACR); 2012.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RenovascularHypertension.pd
2. Moser M, Setaro JF. Resistant or difficult-to-control hypertension. New England Journal of
Medicine, 2006, 355, 385-392.
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RENAL
AB-44~POLYCYSTIC KIDNEY DISEASE
AB-44.1 Polycystic Kidney Disease
 Ultrasound1 (CPT®76770 or CPT®76775) can be performed for:
o Suspected polycystic kidney disease
o Screening individuals at risk for autosomal dominant polycystic disease (ADPKD)
Reference
1. Belibi FA, Edelstein CL. Unified Ultrasonographic Diagnostic Criteria for Polycystic Kidney
Disease. Journal of the American Society of Nephrology, 2009, 20, 6-8.
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Page 65 of 73
URINARY TRACT
AB-45~HEMATURIA
AB-45.1 General Considerations – Hematuria
These guidelines relate to hematuria without flank pain/renal colic
(See AB-5~Flank Pain, Rule out Renal Stone)
Hematuria can be either micro-hematuria or gross hematuria1 (including dipstick
urinalysis, complete urinalysis with microscopic exam, and/or blood creatinine level.
Signs and symptoms of UTI:
 Urinary frequency
 Burning on urination,
 Positive urine leukocyte esterase
 Presence of WBCs in the urine
 Fever
 Elevated WBC >10,000
AB-45.2 Hematuria with Urinary Tract Infection
 Females < 40 should receive at least a 3 day regimen of antibiotics followed by repeat
dipstick urinalysis or complete urinalysis with microscopic exam. If the hematuria
resolves, advanced imaging is not indicated. If symptoms persist, may receive CT
Urogram (CPT®74178)
 Females >40, may undergo CT urogram1 (CPT®74178)
 Males with UTI should be imaged, see AB-46~Urinary Tract Infection
AB-45.3 Hematuria, not Related to Urinary Tract Infection
 CT Urogram (CPT®74178)
 Evidence of primary generalized renal disease should have renal ultrasound
(CPT®76770 or CPT®76775) in order to determine renal volume and morphology,
prior to considering advanced imaging including CT Urogram.
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Page 66 of 73
References
1. Ramchandani P, Kisler T, Francis IR, Casalino DD, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® hematuria. American College of Radiology (ACR); 2008.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/Hematuria.pdf accessed June
18, 2013.
2. Cohen RA, Brown RS. Microscopic hematuria. New England Journal of Medicine, 2003, 348, 23302338.
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Page 67 of 73
URINARY TRACT
AB-46~URINARY TRACT INFECTION (UTI)
 These guidelines refer to UTI without Hematuria.
 For UTI with Hematuria, See AB-45~Hematuria
AB-46.1 Upper (Pyelonephritis)
 CT abdomen and pelvis without and with contrast (CPT®74178) or CT abdomen and
pelvis with contrast (CPT®74177) if1:
o Suspected complicated: diabetes, immune-compromised, history of stones, prior
renal surgery, elevated creatinine, or fever >101 F (>38.5 C)
o Not responding to therapy after 3 days
o Recurrent pyelonephritis (at least 1 prior pyelonephritis)
o Males with first time UTI, or recurrent UTI without etiology
 Pregnant women should be evaluated initially by renal ultrasound2 (CPT®76770 or
CPT®76775) and if further imaging is necessary, MRI abdomen and pelvis3 (contrast
as requested).
AB-46.2 Lower
 CT abdomen and pelvis without and with contrast (CPT®74178) if3:
o Suspected complicated: diabetes or immunocompromised or history of stones or
prior renal surgery, elevated creatinine or fever >101 F(> 38.5 C)
o Not responding to therapy after 3 days
o Males with first time UTI, or recurrent UTI without etiology
o Recurrent UTI >3 per year
o Recommendation by Urologist or specialists
 MRI pelvis without and with contrast (CPT®72197) if:
o Suspected urethral diverticulum or other urethral abnormalities
 Also see PV-13~Periurethral Cysts and Urethral Diverticula in the Pelvis Imaging
Guidelines.
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References
1. Nikolaidis P, Casalino DD, Remer EM, Bishoff JT, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® acute pyelonephritis. American College of Radiology (ACR); 2012.
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/AcutePyelonephritis.pdf
2. Delzell JE, Lefevre ML. Urinary tract infections during pregnancy. American Family Physician,
2000, 61(3), 713-720.
3. Lazarus E, Casalino DD, Remer EM, Arellano RS, et al. Expert Panel on Urologic Imaging. ACR
Appropriateness Criteria® recurrent lower urinary tract infection in women. American College of
http://www.acr.org/~/media/ACR/Documents/AppCriteria/Diagnostic/RecurrentLowerUrinaryTractI
nfectionsWomen.pdf accessed June 18, 2013.
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AB-47~PATENT URACHUS
AB-47.1 Patent Urachus
 CT Pelvis with contrast (CPT®72193) can be performed if ultrasound (CPT®76700 or
CPT®76705) is equivocal, or if needed for surgical planning.1,2
Practice Note
The urachus is a “tube” connecting the fetal bladder to the umbilical cord. It is usually
obliterated during fetal growth, but if it remains patent, there can be a connection
between the bladder and the umbilicus.
References
1. Berrocal T, Lopez-Pereira P, Arjonilla A, Gutierrez J. Anomalies of the distal ureter, bladder, and
urethra in children: embryologic, radiologic, and pathologic features. Radiographics, 2002; 22:
1139-1164.
2. Little DC, Shah SR, St. Peter SD, Calkins CM, et al. Urachal anomalies in children: the vanishing
relevance of the preoperative voiding cystourethrogram. Journal of Pediatric Surgery, 2005; 40:
1874-18765.
3. Yiee JH, et al. A diagnostic algorithm for urachal anomalies. Journal of Pediatric Urology, 2007; 3;
500- 504.
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Page 70 of 73
AB-48~TRANSPLANT
AB-48.1 Liver Transplant, Pre-Transplant
Individuals on the liver transplant waiting list can undergo advanced imaging per that
institution’s protocol as long as the studies do not exceed the following:
See CD-1.6 Transplant Patients in the Cardiac Imaging Guidelines for guidelines on
cardiac stress testing
 If no known Hepatocellular Carcinoma1:
o Liver ultrasound (CPT®76705) with Doppler (CPT®93975) every six months
o CT or MRI abdomen (CPT®74170 or CPT®74183) every year
o CT chest (CPT®71260) for initial placement on the transplant list, but repeat chest
CT scans are not required
o MRI Bone Marrow Blood Supply (CPT®77084) or bone-scan one time
 If known Hepatocellular Carcinoma1,2:
o Liver ultrasound (CPT®76705) with Doppler (CPT®93975) every six months
o CT or MRI abdomen (CPT®74170 or CPT®74183) every three months
o CT chest (CPT® 71260) every six months
o Bone scan every six months
 If known Primary Sclerosing Cholangitis1 (PSC)
o MRCP (see AB-32~MRCP for correct reporting/coding)
 Pre-operative studies immediately prior to liver transplant3:
o CT or MRI abdomen (CPT®74170 or CPT®74183)
 if CT abdomen was most recently done while on the transplant waiting list, then
MRI abdomen should be done immediately prior to transplant and vice versa
o CT pelvis (CPT®72193)
o CTA abdomen (CPT®74175) or MRA abdomen (CPT®74185)
o CT chest (CPT®71260)
o MRI Bone Marrow Blood Supply (CPT®77084) or bone scan
AB-48.2 Liver Transplant, Partial Liver Transplant Donors
 Donors for partial liver transplant can be evaluated with CT of the abdomen without
and with contrast (CPT®74170) or MRI of abdomen without and with contrast
(CPT®74183) prior to transplant
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AB-48.3 Liver Transplant, Post-transplant
See CD-1.6 Transplant Patients in the Cardiac Imaging Guidelines for guidelines on
stress testing
 If known Hepatocellular Carcinoma:
o CT or MRI abdomen (CPT®74170 or CPT®74183) at 6 and 12 months post
transplant, then every year until 5 years post-transplantation, then as clinically
indicated
 If known Cholangiocarcinoma:
o Liver ultrasound (CPT®76705) every 6 months until 5 years post-transplantation
o Chest CT (CPT®72160) every 6 months until 5 years post-transplantation
o MRI abdomen and MRCP (CPT®74183) every 6 months until 5 years posttransplantation
 All other post-transplant patients:
o Abdomen and pelvis CT with contrast (CPT®74178) or with contrast can be
performed for the following:
 Unexplained fever, abdominal pain, anemia, bleeding, weight loss,
lymphadenopathy, enlarged spleen or liver, or other suspected postoperative
complication
AB-48.4 Liver Transplant, Post-Transplant Lymphoproliferative Disease (PTLD)
 Most cases of PTLD are observed in the first year following transplant. Frequency of
developing PTLD:
o Small bowel transplant—20% of patients are at risk of developing PTLD
o Lung transplant—10% risk
o Heart transplant—6% risk
o Liver transplant—1%-3% risk
o Kidney transplant—1%-3% risk
 Evaluation of suspected PTLD is same as evaluation for lymphoma:
(See ONC-28~Lymphomas in the Oncology & PET Imaging Guidelines)
 Chest/abdomen/pelvis CT with contrast (CPT®71260 and CPT®74177) can be
performed. Biopsy of the involved organ should be performed if PTLD is suspected
 There is insufficient evidence-based data to support the routine use of imaging to
screen for PTLD4
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AB-48.5 Kidney Transplant, Pre-Transplant Imaging Studies
See: CD-1.6 Transplant Patients in the Cardiac Imaging Guidelines for guidelines on
cardiac stress testing
Individuals on the kidney transplant waiting list can undergo advanced imaging per that
institution’s protocol as long as the studies do not exceed the following:
 If stress test is positive for reversible ischemia, or if duration of diabetes is >25 years
and patient has additional cardiac risk factors, then diagnostic left heart catheterization
can be performed
 Carotid duplex study (CPT®93880 bilateral study or CPT®93882 unilateral study) if
there is history of stroke, TIA, or if carotid bruit is present on exam
 Abdomen and pelvis CT scan (CPT® 74176 or CPT®74177) one time
AB-48.6 Kidney Transplant, Post-transplant
 Ultrasound of transplanted kidney:
o Current ultrasound imaging protocols of the transplanted kidney commonly include
a Doppler study and are coded as CPT®76776
 Do not report non-invasive vascular codes CPT®93975 and CPT®93976 in
conjunction with CPT®76776
o Ultrasound of the transplanted kidney performed without duplex Doppler should
be reported as a limited retroperitoneal ultrasound (CPT®76775)
AB-48.7 Heart Transplant
o See CD-1.6 Transplant Patients in the Cardiac Imaging Guidelines
References
1. Carruso S, Miraglia R, et al. Imaging in liver transplantation. World Journal of Gastroenterology,
2009, 15(6), 675-683.
2. Pomfret EA, Washburn K, Wald C, Nalesnik MA, et al Report of a national conference on liver
allocation in patients with hepatocellular carcinoma in the United States. Liver Transplant. 2010,
16(3):262-78. http://www.natap.org/2010/HCV/newliver.pdf
3. Sahani D, Mehta A, Blake M, Prasad S, et al. Preoperative Hepatic Vascular Evaluation with CT
and MR Angiography: Implications for Surgery. RadioGraphics 2004;24:1367-1380
4. Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for
management of EBV-associated post-transplant lymphoproliferative disease (PTLD) in solid organ
transplant. http://www.guideline.gov/content.aspx?id=38418 accessed June 18, 2013.
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ABDOMEN IMAGING GUIDELINES MedSolutions, Inc. Clinical Decision Support Tool

Transcription

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