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Description of Noninvasive Vascular Studies
Vascular studies include patient care required to perform the studies,
supervision of the studies and interpretation of study results with copies
for patient records of hard copy output or imaging when provided. The use
of a simple hand-held or other Doppler device that does not produce hard
copy output, or that does not permit analysis of bi-directional vascular
flow, is considered part of the physical examination of the vascular system
and is not separately reimbursable. Doppler procedures performed with
zero-crossers (i.e. analog [strip chart recorder] analysis) are also
included.
CEREBROVASCULAR EXAMINATION
HCPC Codes 93875 and 93880 through 93888
Indications for Cerebrovascular Examination:
1. Cervical bruits
2. Amaurosis fugax
3. Focal cerebral or ocular transient ischemic attacks (i.e., localizing
symptoms, weakness of one side of the face, slurred speech, weakness of a
limb). Ocular transient ischemic attacks are defined as visual field
deficits and not temporary blurred vision.
4. Drop attacks or syncope are rare indications primarily seen with
vertebrobasilar or bilateral carotid artery disease. Incoordianation or
limb dysfunction should be grouped with unilateral weakness of the face or
extremities.
5. CVA
Examples of Signs and Symptoms That Do Not Demonstrate Medical Necessity:
1. Dizziness is not a typical indication unless associated with other
localizing signs or symptoms. However, episodic dizziness with symptom
characteristics typical of transient ischemic attacks may indicate medical
necessity, especially when other more common sources (e.g., postural
hypotension or transiently decreased cardiac output as demonstrated by
cardiac events monitoring) have been previously excluded.
2. Headaches are not an indication of extracranial studies.
Acceptable Procedures for Reimbursement:
1. Duplex scan (93880 or 93882)
2. Doppler ultrasound with spectrum analysis (93875)
3. Oculopneumoplethysmography (OPPG) (93875)
4. Periorbital Doppler (93875) when OPPG is contraindicated
5. Transcranial Doppler (TCD) (see below) (93886 or 93888)
Multiple cerebrovascular procedures can be allowed during the same
encounter given the provider can demonstrate medical necessity. That is,
physiologic studies and a duplex scan are allowed on the same date of
service given the provider is able to document medical necessity (e.g.,
greater than or equal to 50% stenosis on duplex scan or significant
symptoms as demonstrated by the indications for the study) on post-payment
audit.
Methods not Acceptable for Reimbursement:
1. Pulse delay oculoplethysmography
2. Carotid phonoangiography and other forms of bruit analysis are covered
services but are included in the reimbursement for the office visit
3. Periorbital photoplethysmography
Recommendations for Follow-up Studies:
1. Stenosis of 20-50%, an annual study
2. Stenosis of 50-79%, every six months
3. Stenosis of 80-99%, surgery is usually recommended
4. After carotid endarterectomy, repeat examinations are allowed at six
weeks, six months, one year and annually thereafter
Transcranial Doppler (TCD) (93886 or 93888)
TCD is an allowed procedure and is of established value in:
1. Detecting severe stenosis (> 65%) in the major basal intracranial
arteries
2. Assessing patterns and extent of collateral circulation in patients with
known regions of severe stenosis or occlusion
3. Evaluating and following patients with vasoconstriction of any cause
especially after subarachnoid hemorrhage
4. Detecting arteriovenous malformations and studying their supply arteries
and flow patterns
5. Assessing patients with suspected brain death
6. Shunt study evaluation as the etiology of CVA’s
Examples of non-acceptable indications include:
1. Evaluation of brain tumors
2. Assessment of familiar and degenerative diseases of the cerebrum,
brainstem, cerebellum, basal ganglia and motor neurons
3. Evaluation of infectious and inflammatory conditions
4. Psychiatric disorders
5. Epilepsy
The following applications are in the research phase and are considered
investigational:
1. Assessing patients with migraine
2. Monitoring during carotid endarterectomy cardiopulmonary bypass and
other cerebrovascular and cardiovascular interventions, and surgical
procedures
3. Evaluation of patients with dilated vasculopathies such as fusiform
aneurysms
4. Assessing autoregulation, physiologic, and pharmacological response of
cerebral arteries
5. Evaluating children with various vasculopathies such as sickle cell
disease, moya moya, and neurofibromatosis
PERIPHERAL ARTERIAL EXAMINATION
HCPC Codes 93922 through 93931
Noninvasive peripheral arterial examinations, performed to establish the
level and/or degree of arterial occlusive disease, are medically necessary
if (1) significant signs and/or symptoms of limb ischemia are present and
(2) the patient is a candidate for invasive therapeutic procedures. A routine
history and physical examination, which includes Ankle/Brachial Indices
(ABIs), can readily document the presence or absence of ischemic disease in
a majority of cases.
An ABI should be abnormal (i.e., <0.9 at rest) and must be accompanied
by another appropriate indication before proceeding to more sophisticated
or complete studies, except in patients with severe diabetes resulting in
medial calcification as demonstrated by artifactually elevated ankle blood
pressures.
Indications for Peripheral Arterial Evaluations
1. Claudication of less than one block or of such severity that it
interferes significantly with the patient’s occupation or lifestyle. Also
abnormal ABIs and/or segmented pressures.
2. Rest pain (typically including the forefoot), usually associated with
absent pulses, which becomes increasingly severe with elevation and
diminishes with placement of the leg in a dependent position.
3. Tissue loss defined as gangrene or pregangreneous changes of the
extremity, or ischemic ulceration of the extremity occurring in the absence
of pulses.
4. Aneurysmal disease
5. Evidence of thromboembolic events
6. Blunt or penetrating trauma (including complications of diagnostic
and/or therapeutic procedures)
7. For evaluation of dialysis access, see policy regarding CPT code 93990
Examples of Signs and Symptoms that Do Not Indicate Medical Necessity
1. Continuous burning of the feet is considered to be a neurologic symptom.
2. "Leg Pain, nonspecific," and "Pain in limb" as a
single diagnosis are too general to warrant further investigation unless
they can be related to other signs and symptoms.
3. Edema rarely occurs with arterial occlusive disease unless it is in the
immediate postoperative period, in association with another inflammatory
process or in association with rest pain.
4. Absence of relatively minor pulses (i.e., dorsalis pedis or posterior
tibial) in the absence of symptoms. The absence of pulses is not an
indication to proceed beyond the physical examination unless it is related
to other signs and/or symptoms
Acceptable Procedures for Reimbursement
1. Duplex scan (93925, 93926, 93930, or 93931)
2. Single level physiologic studies (e.g., Doppler waveform analysis, volume
plethysmography, granscutaneous oxygen tension measurement) (93922)
3. Segmental physiologic studies or with provacative functional maneuvers
(93923)
4. Physiologic studies at rest and following treadmill stress testing
(93924)
Transcutaneous oxygen tension measurements are acceptable to evaluate
healing potential in nonhealing or difficult to heal wounds at a frequency
of no greater than twice in any 60 day period.
Duplex scanning and physiologic studies are reimbursed during the same
encounter if the physiologic studies are abnormal and/or to evaluate
vascular trauma, thromboembolic events or aneurysmal disease.
Methods Not Acceptable for Reimbursement
1. Mechanical Oscillometry
2. Inductance Plethysmography
3. Capacitance Plethysmography
4. Photoelectric Plethysmography
5. ABI (considered part of the physical examination)
Post-Intervention Follow-up Studies
Duplex post-interventional follow-up studies are typically limited in scope
and unilateral in nature. Consequently, the "complete" duplex
scan codes (i.e., 93925 or 93930) should seldom be used while the
"unilateral or limited study codes" (i.e., 93926 or 93931) should
be typically used:
1. In the immediate post-operative period, patients may be studied if
re-established pulses are lost, become equivocal, or if the patient
develops related signs and/or symptoms of ischemia with impending repeat
intervention.
2. Follow-up studies may be appropriate at three month intervals the first
year, six month intervals, the second year and annually thereafter for
autogenous bypass surgeries, post-angioplasty and synthetic graft
insertions of the lower extremities
Screening of the asymptomatic patient is not covered by Medicare.
PERIPHERAL VENOUS EXAMINATIONS
HCPCS Codes 93965 through 93971
Indications for venous examinations are separated into two major
categories: deep vein thromobsis and chronic venous insufficiency. Studies
are medically necessary only if the patient is a candidate for
anticoagulation or invasive therapeutic procedures.
Since the signs and symptoms of arterial occlusive disease and venous
disease are so divergent, the performance of simultaneous arterial and
venous studies during the same encounter should be rare. Consequently, a
document clearly supporting the medical necessity of both procedures
performed during the same encounter must be available for post-payment
audit.
Deep Vein Thrombosis (DVT)
VT is the most common vascular disorder that develops in hospitalized
patients and can develop after trauma or prolonged immobility (sitting or
bedrest). Unfortunately, the signs and/or symptoms of DVT are relatively
non-specific and, due to the risk associated with pulmonary embolism (PE),
objective testing is allowed in patients that are candidates for
anticoagulation or invasive therapeutic procedures for the following
indications:
1. Clinical signs and/or symptoms of DVT including edema, tenderness,
inflammation, and/or erythema
2. Clinical signs and/or symptoms of PE including hemoptysis, chest pain,
pnea, hypoxia and/or respiratory failure
3. Unexplained lower extremity edema status-post major surgical procedures
4. High risk patients: hip surgery, multiple trauma, malignancy, etc.
Bilateral limb edema in the presence of signs and/or symptoms of congestive
heart failure. exogenous obesity and/or arthritis should rarely be an
indication except in high risk populations (e.g., status-post major
surgical procedures).
Chronic Venous Insufficiency
Chronic venous insufficiency may be divided into three categories: primary
varicose veins, post-thrombotic (post-phlebitic) syndrome, and recurrent
DVT. It is not medically necessary to study primary varicose veins.
Objective tests of venous function may be indicated in patients with
ulceration suspected to be secondary to venous insufficiency in order to
confirm this diagnosis by documenting venous valvular incompetence prior to
treatment. Evaluation is medically necessary in patients with symptoms of
recurrent DVT.
Acceptable Procedures for Reimbursement
1. Duplex scan (93970 or 93971)
2. Doppler waveform analysis including responses to compression and other
maneuvers (93965)
3. Impedance Plethysmography (93965)
4. Air Plethysmography (93965)
5. Strain Gauge Plethsmography (93965)
Methods Not Acceptable for Reimbursement
1. Mechanical Oscillometry
2. Inductance Plethysmography
3. Capacitance Plethysmography
4. Photoelectric Plethysmography
Performance of both duplex scanning (93970 or 93971) and physiological tests
(93965) of extremity veins during the same encounter is not medically
necessary.
HEMODIALYSIS ACCESS EXAMINATION
HCPCS Code 93990
Limited coverage has been established for duplex scanning of hemodialysis
access sites in patients with end stage renal disease (ESRD). These
procedures are medically necessary only in the presence of signs or
symptoms of possible failure of the access site and when the results may
impact the clinical course of the patient.
Appropriate indications for Duplex scan of hemodialysis access sites
include:
1. ICD-9-CM code 996.73: Complication (Complication NOS, occlusion NOS,
embolism, fibrosis, hemorrhage, pain, stenosis, thrombosis) due to renal
dialysis device, implant, and graft.
Clear documentation in the dialysis record of signs of chronic (i.e., 3
successive dialysis sessions) of abnormal function including:
a. difficult cannulation by multiple personnel
b. thrombus aspiration by multiple personnel
c. elevated venous pressure greater than 200 mmHg on a 300 cc/min pump
d. elevated recirculation time of 15% or greater
e. low urea reduction rate of less than 60%, or
f. shunt collapse suggesting poor arterial inflow
Routine evaluation on a daily or weekly basis without evidence of the above
is considered screening and is not a covered service.
ULTRASOUND GUIDED REPAIR OF PSEUDOANEURYSM
HCPC Code 76936
Diagnosis of pseudoaneurysm is primarily based on history and physical
examination. The code 76936 includes codes 93926 and 93931, and these
procedures are not separately reimbursable.
Acceptable indications include a pulsatile mass indicating a
pseudoaneurysm. When performed in conjunction with the invasive procedure,
76936 is considered part of the invasive procedure and is not separately
reportable.
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