Non-invasive vascular diagnostic studies utilize ultrasonic Doppler and physiologic principles to assess irregularities in blood flow in arterial and venous systems. The display may be a two-dimensional image with spectral analysis and color flow or a plethysmographic recording that allows for quantitation analysis.
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 imaged when provided.
The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation for post-payment audit.
Effective January 1, 1999, all non-invasive vascular diagnostic studies must be performed under at least one of the following settings: (1) performed by a physician who is competent in diagnostic vascular studies or under the general supervision of physicians who have demonstrated minimum entry level competency by being credentialed in vascular technology, or (2) performed by a technician who is certified in vascular technology, or (3) performed in facilities with laboratories accredited in vascular technology.
Examples of appropriate personnel certification include, but are not limited to the Registered Vascular Technologist (RCT), the Registered Cardiovascular Technologist (RCVT) and the American Registry of Radiologic Technologists (ARRT) credentials in vascular technology. Appropriate laboratory accreditation includes the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).
Definitions:
· A duplex scan implies an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectrum analysis and/or color flow velocity mapping or imaging.
· A physiologic study implies functional measurement procedures including Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmography.
· Plethysmography implies volume measurement procedures including air, impedance, or strain gauge methods.
· Transcranial Doppler uses ultrasound principles to emit high frequency soundwaves from a Doppler device to detect the flow of blood or pinpoint an arterial irregularity such as an obstruction in the arteries within the cranium (skull).
General Indications
- Non-invasive vascular studies are used for the evaluation of patients with either arterial or venous diseases. The studies are often used prior to invasive studies or to define surgical intervention.
General Limitations
· The services outlined in this policy will not be covered if they are performed using simple hand held or other doppler devices that do not produce hard copy output, or devices that do not permit analysis of the bi-directional vascular flow or doppler procedures performed with zero-crossers (i.e. analog [strip chart recorder] analysis).
· Medicare does not pay for routine screening tests. ICD-9-CM diagnosis code V82.9 (special screening of other conditions, unspecified condition) should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of ICD-9-CM code V82.9 will result in the denial of claims as non-covered screening services.
· It is seldom necessary to perform arterial and venous studies during the same encounter. Documentation should be available to support the medical necessity for both studies.
· The Correct Coding Initiative precludes billing codes 93925, 93926, 93930, 93931, 93970, and 93971 on the same day as HCPCS code G0365. It also precludes billing HCPCS code G0365 on the same day as codes 93922,93923, and 93965.
· It is rarely necessary to perform cerebrovascular and upper extremity studies on the same day. Documentation supporting the need for both studies should be available for review.
· A referral must be on record for each non-invasive study performed. A referral for one type of study does not qualify as a referral for all tests.
CEREBROVASCULAR ARTERIAL STUDIES (codes 93875-93892)
Indications:
Cerebrovascular arterial studies are considered for Medicare payment when at least one of the following conditions is present:
- Cervical bruits
- Amaurosis fugax
- Focal cerebral or ocular transient ischemic attacks (including but not limited to localizing symptoms, weakness of one side of the face, slurred speech, weakness of a limb, ocular microembolism, arterial occlusions on retinal examination (branch or central), optic nerve/retinal/ocular ischemia, suspected dural or carotid cavernous fistulae).
- Drop attacks or syncope are rare indications primarily seen with vertebrobasilar or bilateral carotid artery disease.
- Episodic dizziness with symptom characteristics typical of transient ischemic attacks, 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.
- Cerebral vasospasm complicating subarachnoid hemorrhage
- Impending invasive therapeutic interventions for cerebral arteriovenous malformations
- Intracranial hemodynamic abnormalities in patients with suspected brain death
- Intraoperative and perioperative monitoring of intracranial flow velocity and hemodynamic patterns during carotid endarterectomy (This is usually a Part A responsibility, unless the professional component is performed by a physician who is not a member of the operating team.)
- Cerebral embolization
- Evaluation and follow-up of asymptomatic bruits
Limitations:
The following conditions would not meet medical necessity criteria for coverage:
- Headaches (including migraines)
- Dizziness, unless associated with other localizing symptoms
- Assessment of familial and degenerative diseases of the cerebrum, brainstem, cerebellum, basal ganglia and motor neurons
- Epilepsy
- Psychiatric disorders
- Brain tumors
- Evaluation of infectious and inflammatory conditions
The following conditions are considered investigational applications and are not covered:
- Migraine
- Monitoring during carotid endarterectomy, cardiopulmonary bypass and other cerebrovascular and cardiovascular interventions.
- Evaluation of patients with dilated vasculopathies such as fusiform aneurysms
- Assessing autoregulation, physiologic, and pharmacological responses of cerebral arteries
PERIPHERAL ARTERIAL EXAMINATIONS (codes 93922-93931)
Indications
Peripheral arterial studies are considered for Medicare coverage when there are significant signs and/or symptoms of possible limb ischemia in a patient who may be a candidate for invasive therapeutic procedures, as indicated by at least one of these conditions:
- Claudication of such severity that it interferes significantly with the patient’s occupation or lifestyle.
- 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.
- Tissue loss defined as gangrene or pregangrenous changes of the extremity, or ischemic ulceration of the extremity occurring in the absence of pulses.
- Aneurysmal disease
- Evidence of thromboembolic events
- Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures
- Follow-up grafts
Limitations:
1. The following conditions would not meet medical necessity criteria for coverage:
- "Leg pain, nonspecific" and "pain in limb" as a single diagnosis is too general to warrant further investigation unless they are related to other signs and symptoms.
- Edema rarely occurs with arterial occlusive disease unless it is the immediate postoperative period, in association with another inflammatory process or in association with rest pain.
- Absence of relatively minor pulses (such as isolated dorsalis pedis or posterior tibial) in the absence of symptoms is not an indication to proceed beyond the physical examination unless it is related to other signs or symptoms.
2. Calculation of the ankle/brachial index (ABI) is considered to be part of the peripheral vascular study, and is therefore not separately payable. If the provider uses a device that does not meet the specifications for coverage outlined in the “General Limitations” section of the LCD, the determination of the ABI should be added to the amount and complexity of data in the medical decision making portion of the E&M service.
PERIPHERAL VENOUS EXAMINATIONS (codes 93965-93971)
Indications
These studies are medially necessary in patients who are candidates for anticoagulation, thrombolysis, or invasive therapeutic procedures and who have signs or symptoms of one of the following:
- Deep vein thrombosis (DVT) indicated by edema, tenderness, inflammation, and/or erythema
- Pulmonary embolism (PE) indicated by hemoptysis, chest pain, and/or dyspnea
- Unexplained lower extremity edema status-post major surgical procedures
- Chronic venous insufficiency indicated by secondary varicose veins
- Post-thrombotic (post-phlebitic) syndrome
- Ulceration suspected to be secondary to venous insufficiency
- Primary varicose veins with symptoms (e.g., pain, swelling)
- Venous mapping for the selection of a vein suitable for creating a dialysis fistula or prior to revascularization by reducing the time necessary for the surgery.
Note:
Venous mapping is not always indicated as a routine pre-operative study. However, if the patient’s clinical evaluation does not readily lead to the selection of a vein that is suitable for creating a dialysis fistula, the venous mapping would be considered medically necessary. This procedure may also be useful prior to revascularization by reducing the time necessary for the surgery. Effective for services performed on or after June 1, 1999, is considered a covered service in either of these situations when performed once prior to the surgical procedure (i.e., hemodialysis site being surgically created or revascularization). In either situation, procedure code 93990/G0365 should be reported with ICD-9-CM code V72.83. When this service is performed in a hospital setting, only the professional component (modifier 26) should be billed to Medicare Part B.
Limitations
The following conditions would not meet medical necessity criteria for coverage:
- It is not medically necessary to perform duplex scans (93970, 93971) and physiological tests (93965) during the same encounter.
- 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.
- It is not medically necessary to perform peripheral venous examinations to study primary varicose veins that are not symptomatic.
VISCERAL VASCULAR STUDIES (93975, 93976, 93978, 93979)
Indications
Visceral vascular studies are considered for Medicare payment when one of the following conditions is present:
- Arteriosclerosis of renal artery
- Aortic aneurysm and dissection
- Peripheral vascular disease
- Intestinal vascular insufficiency
- Intestinal angiodysplasia (this indication requires expert hands with selective ICAVL accreditation)
NOTE:For procedure codes 93980 and 93981 and for diagnosis of erectile dysfunction, refer to Empire's policy YSURG #27.
HEMODIALYSIS ACCESS EXAMINATION (HCPCS code 93990)
Indications:
Medicare will consider separate payment for vascular studies ( CPT code 93990) on symptomatic ESRD patients, when Doppler flow studies are used to provide diagnostic information to determine the appropriate medical intervention. Medicare considers a Doppler flow study medically necessary when the beneficiary’s dialysis access site manifests signs or symptoms associated with vascular compromise, and when the results of this test are necessary to determine the clinical course of treatment.
Signs or symptoms in patients with ESRD of impending failure of the hemodialysis access site, including:
- Elevated venous pressure > 200mm HG on a 200 cc/min. pump
- Elevated recirculation of time of 12 percent or greater, and
- Low urea reduction rate < 60 percent
- An access with a palpable "water hammer" pulse on examination (which implies venous outflow obstruction)
VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (HCPCS CODE G0365)
Indications:
Vessel mapping of vessels for hemodialysis access is considered for Medicare payment when it is performed preoperatively prior to creation of hemodiaysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow.
Limitations:
· Medicare will limit payment to either a Doppler flow study (93990) or an angiogram (fistulogram, venogram, 75790 with 36145 or 75820 with 36005), but not both, unless documentation is provided to support the medical necessity for both studies.
An example of a clinical situation demonstrating the need for both studies would be a scenario where a Doppler flow study demonstrates reduced flow (blood flow rate less than 800cc/min or a decreased flow of 25% or greater from previous study), and the physician requires an arteriogram, to define the extent of the problem. The patient's medical record(s) must provide documentation supporting the need for more than one imaging study.
· If the service is done for monitoring purposes, it is not covered under Part B.
· No separate payment for non-invasive vascular studies for monitoring the access site of an ESRD patient, whether coded as the access site or peripheral site, is permitted to any entity.
· The technical component of HCPCS code G0365 and CPT code 93990 (modifier TC) performed in ESRD facilities or for ESRD patients is included in the composite payment rate. This rate is a comprehensive payment that includes all services, equipment, supplies and certain laboratory tests and drugs that are necessary for dialysis treatment.
· The professional component for the procedure (modifier 26) is included in the monthly capitation payment (MCP) if billed by the MCP physician. Physicians other than the MCP provider may bill separately for interpretations of tests.
· Services performed on ESRD patients by entities outside the ESRD facility must bill the ESRD facility for payment.
· Unless documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study (CPT code 93990/HCPCS code G0365) or an arteriogram (fistulogram, venogram,-CPT codes 75790/75820), but not both.
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