Revised Final Policy OTH-9726
Cahaba Government Benefit Administrators
00512
Medicare Part B Carrier

LMRP Title:

Noninvasive Vascular Studies

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 2001 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

CMS’ National Coverage Policy:

Thermography, mechanical oscillometry, inductance plethysmography, capacitance plethysmography, and photoelectric plethysmography are not covered services. Light reflection rheography is not a covered service based on a lack of documentation of medical necessity in the current literature.
Section 1862(a)(1)(A) of the Social Security Act states that Medicare will cover only those services and procedures that are "reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member." Section 1862(a)(7) states that Medicare will not cover any services or procedures associated with "routine physical checkups."

Primary Geographic Jurisdiction:

Mississippi Medicare Providers

Secondary Geographic Jurisdiction:

N/A

CMS Region:

IV

CMS Consortium:

Southern

Original Policy Effective Date:

02/01/1998

Original Policy Ending Date:

N/A

Revision Effective Date:

N/A

Revision Ending Date:

N/A

LMRP Description:

Vascular studies include patient care required to perform the studies, supervision of the studies, and interpretation of study results with copies per 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. That accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skills, 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. Further, effective January 1,1998, noninvasive vascular diagnostic studies in Mississippi must be either (1) performed by persons that have demonstrated minimum entry level competency by being credentialed in vascular technology, (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in vascular technology. Direct supervision in the office setting means the physicians must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

CPT code 76936 requires that the procedure be performed under the personal supervision of a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

Thermography, mechanical oscillometry, inductance plethysmography, capacitance plethysmography, and photoelectric plethysmography are not covered services. Light reflection rheography is not a covered service based on lack of documentation of medical necessity in the current literature.
It is the responsibility of the provider to ensure the medical necessity of procedures and to maintain a record for postpayment audit. Noninvasive vascular studies are medically necessary only if the outcome will potentially impact that clinical course of the patient. That is, if it is obvious from the findings of the history and physical examination that the patient is the one to proceed to angiography, then noninvasive vascular studies are not medically necessary.

A duplex scan includes a real-time scan (see CPT-4; Diagnostic Ultrasound). Consequently, billing for both a duplex scan and echography of the same body part represents unbundling and is not allowed.

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.

Physiologic Studies: Implies functional measurement procedures including Doppler ultrasound studies, blood pressure measurement, transcutaneous oxygen tension measurement, or plethysmography.

Plethysmography: Implies volume measurement procedures including air, impendance, or strain gauge methods. Noninvasive peripheral arterial examination, perform to establish the level and/or degree of arterial occlusive disease, is medically necessary if (1) significant signs and/or symptoms a possible 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. It is not medically necessary to proceed beyond the physical examination for minor signs and symptoms such as hair loss, absence of a single pulse, relative coolness of a foot, shiny thin skin, or lack of toe nail growth unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

An ABI (1) is not a reimbursable procedure in itself, and (2) 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 medical calcification has demonstrated by artifactually elevated ankle blood pressures.

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 typically be used.

1. In the immediate post-operative period, patients may be studied if re-established pulses are lost, become equivocal, or in the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.

2. With regard to autogenous lower extremities vein bypass surgeries, a study can be performed at three-month intervals during the first year, at six-month intervals during the second year, and annually thereafter. Follow-up studies are not medically necessary post-angioplasty in the absence of signs and/or symptoms of ischemia. Synthetic grafts may be studies if the patient develops signs and/or symptoms of occlusive disease.

3. In general, noninvasive studies of the arterial system are to be utilized when invasive correction is contemplated, but not to follow noninvasive medical treatment regimens. The latter may be followed with physical findings and/or progression or relief of signs and/or symptoms. Screening of the asymptomatic patient is not covered by Medicare.

Indications and Limitations of Coverage and/or Medical Necessity:

Cerebrovascular Arterial Studies (CPT Codes 93875 - 93888)

Indications for Cerebrovascular Evaluations:

Cervical bruits

1. Amaurosis fugax

2. Focal cerebral or ocular ischemic attacks (i.e., localizing symptoms, weakness of one-side of the face, slurred speech, weakness of a limb). Visual transient ischemic attacks are defined as retinal or hemispheric visual field deficiency and not temporary blurred vision.

3. Drop attacks or syncope are rare indications primarily seen with vertebrobasilar or bilateral carotid artery disease. Incoordination limb dysfunction should be grouped with unilateral weakness of the phase or extremities.

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 cardial output as demonstrated by cardiac events monitoring) have been previously excluded.

2. Headaches are not an indication for extracranial studies.

Acceptable Procedures 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 on post-payment audit. That is, physiologic studies and a duplex scan are allowed on the same date of service given the provider is about to document medical necessity (e.g., greater than or equal to 50% stenosis on duplex scan significant symptoms as demonstrated by the indications for the studied) 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% (diameter reduction), and 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, and one year. During the first year, follow-up studies should be unilateral unless signs and symptoms provide indication for a bilateral procedure.

Transcranial Doppler (TCD) (93886 or 93888)

The accuracy of TCD examinations depends on the knowledge, skills, and experience of the technologist and interpreter. Consequently, the providers of TCD studies must be capable of demonstrating documented training and experience and maintain documentation for post payment audit. An example of acceptable training and experience would be a physician and/or registered vascular technologist with documentation of attendance at a formal TCD training program that includes hands on experience and results in a certificate of proficiency, and with a minimum experience of 100 patient TCD examination.
TCD is an allowed procedure and is of established value in:

1. Detection and evaluation of the hemodynamic effects of severe stenosis or occlusion of the extracranial (greater than or equal to 60% diameter reduction) and major basal intracranial arteries (greater than or equal to 50% diameter reduction).

2. Detection and serial evaluation of cerebral vasospasm complicating subarachnoid hemorrhage.

3. Evaluation of invasive therapeutic interventions for cerebral arteriovenous malformation.

4. Evaluation top intracranial hemodynamic abnormalities in patients with suspected brain death.

5. Intraoperative and perioperative monitoring of intracranial flow velocity and hemodynamic patterns during carotid endarterectomy. This is primarily a Medicare Part A procedure but the professional component could be reimbursed given it is provided during the operative procedure by a physician that is not a member of the operating team. Evaluation is cerebral embolization.

Examples of Non-acceptable Indications Include:

1. Evaluation of brain tumors

2. Assessment of familial and degenerative diseases of the cerebrum, brain stem, cerebellum, basal ganglia and motor neurons

3. Evaluation of infectious and inflammatory condition

4. Psychiatric disorders

5. Epilepsy

The following applications are in the research stage 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 (except during carotid endarterectomy, as noted above)

3. Evaluation of patients with dilated vasculopathies such as fusiform aneurysms

4. Assessing autoregulation, physiologic, and pharmacological responses of cerebral arteries

Peripheral Arterial Examinations (CPT Codes 93922 – 93931)

Indications for Peripheral Arterial Evaluations:

1. Claudication of less than one block or of such severity that it interferes significantly with the patients occupation or lifestyle

2. Rest pain (typically including the forefoot), usually associated with absent pulses which becomes increasingly severe with elevation and diminishes it with placement the leg in a dependent position

3. Tissue loss defined as gangrene or preangrenous 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 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 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, transcutaneous oxygen tension measurement (93922)

3. Segmental physiologic studies or with provocative functional maneuvers (93923)

4. Physiologic studies at rest and following treadmill stress testing (93924)

A complete extremity physiologic study includes pressure measurements and an additional physiologic technique (e.g., Doppler ultrasound study or plethysmography).

Transcutaneous oxygen tension measurements are acceptable to evaluate healing potential in non-healing or difficult to heal wounds at a frequency of no greater than twice in any 60 day period.

Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease given the provider can document medical necessity.

Methods Not Acceptable for Reimbursement:

1. Mechanical Oscillometry

2. Inductance Plethysmography

3. Photoelectric Plethysmography

4. ABI (considered part of the physical examination)

Peripheral Venous Examinations (CPT Codes 93965 – 93971)

Indications for Peripheral Venous Examinations:

Indications for venous examinations are separated into two major categories: deep vein thrombosis and chronic venous insufficiency. Studies are medically necessary only if the patient is a candidate for anti-coagulation, thrombolysis 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 this same encounter should be greater. Consequently, a document clearly supporting the medical necessity of both procedures performed during the same encounter must be available for post payment audit.

Deep Vain Thrombosis (DVT):

DVT is the most common vascular disorder that develops in hospitalized patients and can develop after trauma or prolonged immobility (sitting or better rest). 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 anti-coagulation 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, and/or dyspnea

3. Unexplained lower extremity edema status-post major surgical procedures

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.

Chronic Venous Insufficiency:

Chronic venous insufficiency may be divided into three categories: primary varicose veins, secondary varicose veins and post-thrombotic (post-phlebitic) syndrome. It is not medically necessary to study primary varicose veins. Objective test of venous function may be indicated in patients with ulceration suspected to be secondary to venous insufficiency in incompetent prior to treatment.

Acceptable Procedures for Reimbursement:

1. Duplex scan (93970 or 93971)

2. Doppler waveform analysis including responses to compressions and other maneuvers (93965)

3. Impedance Plethysmography (93965)

4. Air Plethysmography (93965)

5. Strain Gauge Plethysmography (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 (03065) of extremity veins during the same encounter is not medically necessary.

Follow-up Studies:

Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the provider to maintain documentation of medical necessity for post payment audit.

Heomdialysis Access Examination (CPT Code 93990)

Indications:

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 impending failure of the access site and when the results may impact the clinical course of the patient.

Examples supporting the medical necessity for Doppler flow studies include:

a. Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min;

b. Access re-circulation of 12 percent or greater;

c. An otherwise unexplained urea reduction ratio <60 percent;

d. An access with a palpable pulse on examination;

e. 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;

f. Clear documentation in the dialysis record of signs of chronic (i.e., three successive dialysis sessions) abnormal functioning including: difficult cannulation by multiple personnel or thrombus aspiration by multiple personnel; and

g. Low urea reduction rate of less than 60% shunt collapse suggesting poor arterial inflow.

Limitations:

Routine evaluation on a daily or weekly basis without evidence of the above is considered screening and is not a covered service.

When services are provided by the ESRD physician of record, services are considered renal related and part of the physicians monthly capitated fee and a not separately reportable. Medically necessary services that are included or bundled into the monthly capitated fee (e.g., test interpretations) are separately payable when furnished by physicians other than the ESRD physician of record.

Services performed by Medicare approved ESRD facilities are covered services under the composite rate of the facility and therefore not separately reimbursable.

Unless the documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram), but not both.

An example of when both studies may be clinically necessary is when 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 further define the extent of the problem. The patient's medical record(s) must provide documentation supporting the need for more than one imaging study.

Ultrasound Guided Repair of Psuedoaneurysm (CPT Code 76936)

Diagnosis of psuedoaneurysm is primarily based on history and physician examination.

Consequently, CPT code 76936 includes CPT codes 93926 through 93931 and these procedures are not separately reimbursable. The medical necessity of ultrasound guided repair of arteriovenous fistulae is not supported by a review of the current literature and is, therefore, not reimbursable.

Acceptable indications include a pulsatile mass indicating a psuedoaneurysm and the patient must be at least three days status-post invasive vascular procedure. When performed in conjunction with the invasive procedure, 76936 is considered part of the invasive procedure and is not separately reportable.

CPT/HCPCS Section & Benefit Category:

Radiology, Medicine

Type of Bill Code:

N/A

Revenue Code:

N/A

CPT/HCPCS Code(s):

76936 Ultrasound guided compression repair of arterial pseudo-aneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging

93875-93990 Non-Invasive Vascular Diagnostic Studies

ICD-9-CM Codes That Support Medical Necessity:

76936
414.19 Aneurysm of heart, other
417.0 Arteriovenous fistula of pulmonary vessels
442.9 Other aneurysm of unspecified site
93875-93888
342.00 Flaccid hemiplegia affecting unspecified site
342.01 Flaccid hemiplegia affecting dominant side
342.02 Flaccid hemiplegia affecting non-dominant side
342.10 Spastic hemiplegia affecting unspecified site
342.11 Spastic hemiplegia affecting dominant side
342.12 Spastic hemiplegia affecting non-dominant side
342.80 Other specified hemiplegia affecting unspecified site
342.81 Other specified hemiplegia affecting dominant side
342.82 Other specified hemiplegia affecting non-dominant side
342.90 Hemiplegia, unspecified affecting unspecified site
342.91 Hemiplegia, unspecified affecting dominant side
342.92 Hemiplegia, unspecified affecting non-dominant side
44.00 Quadriplegia, unspecified
344.01 Quadriplegia, C1-C4 complete
344.02 Quadriplegia, C1-C4 incomplete
344.03 Quadriplegia, C5-C7 complete
344.04 Quadriplegia, C5-C7 incomplete
344.09 Quadriplegia, other
344.1 Paraplegia
344.2 Diplegia of upper limbs
344.30 Monoplegia of lower limb, affecting unspecified side
344.31 Monoplegia of lower limb, affecting dominant sid
344.32 Monoplegia of lower limb, affecting non-dominant side
344.5 Unspecified monoplegia
344.9 Paralysis, unspecified
362.21 Other proliferative retinopathy; retrolental fibroplasia
362.34 Transient arterial occlusion
362.84 Retinal ischemia
368.40 Visual field defects, unspecified
368.41 Visual field defects, scotoma involving central area
368.42 Visual field defects, scotoma of blind spot area
368.43 Visual field defects, sector of arcuate defects
368.44 Visual field defects, other localized visual field defect
368.45 Visual field defects, generalized contraction or constriction
368.46 Visual field defects, homonymous bilateral field defects
368.47 Visual field defects, hetronymous bilateral field defects
368.10 Subjective visual disturbance, unspecified
368.11 Sudden visual loss
433.00 Occlusion and stenosis of precerebral arteries, basilar artery without mention of cerebral infarction
433.01 Occlusion and stenosis of precerebral arteries, basilar artery with cerebral infarction
433.10 Occlusion and stenosis of precerebral arteries, carotid artery without mention of cerebral infarction
433.11 Occlusion and stenosis of precerebral arteries, carotid artery with cerebral infarction
433.20 Occlusion and stenosis of precerebral arteries, vertebral artery without mention of cerebral infarction
433.21 Occlusion and stenosis of precerebral arteries, vertebral artery with cerebral infarction
433.30 Occlusion and stenosis of precerebral arteries, multiple and bilateral without mention of cerebral infarction
433.31 Occlusion and stenosis of precerebral arteries, multiple and bilateral with cerebral infarction
433.80 Occlusion and stenosis of precerebral arteries, other specified precerebral artery without mention of cerebral infarction
433.81 Occlusion and stenosis of precerebral arteries, Other specified precerebral artery with cerebral infarction
434.00 Cerebral thrombosis without mention of cerebral infarction
434.01 Cerebral thrombosis with cerebral infarction
434.10 Cerebral embolism without mention of cerebral infarction
434.11 Cerebral embolism with cerebral infarction
434.90 Cerebral artery occlusion, unspecified without mention of cerebral infarction
434.91 Cerebral artery occlusion, unspecified with cerebral infarction
435.0 Basilar artery syndrome
435.1 Vertebral artery syndrome
435.2 Subclavian steal syndrome
435.3 Vertebrobasilar artery syndrome
435.8 Other specified transient cerebral ischemias
435.9 Unspecified transient cerebral ischemia
436 Acute, but ill-defined, cerebrovascular disease
437.3 Cerebral aneurysm, non-ruptured
437.4 Cerebral arteritis
437.7 Transient global amnesia
442.81 Artery of neck
442.82 Subclavian artery
446.0 Polyarteritis nodosa
446.20 Hypersensitivity angiitis, unspecified
446.21 Goodpasture’s syndrome
446.4 Wegener’s granulomatosis
446.5 Giant cell arteritis
46.6 Thrombotic microangiopathy
446.7 Takayasu’s disease
780.2 Syncope and collapse
780.4 Dizziness and giddiness
781.2 Abnormality of gait
781.3 Lack of coordination
781.4 Transient paralysis of limb
782.0 Disturbance of skin sensation
784.3 Aphasia
784.5 Other speech disturbance
785.9 Other symptoms involving cardiovascular system
900.01 Injury to blood vessels of head and neck, common carotid artery
900.02 Injury to blood vessels of head and neck, external carotid artery
900.03 Injury to blood vessels of head and neck, internal carotid artery
900.1 Injury to blood vessels of head and neck, internal jugular vein
900.81 Injury to blood vessels of head and neck, external jugular vein
900.82 Injury to blood vessels of head and neck, multiple blood vessels of head and neck
900.89 Injury to blood vessels of head and neck, other
901.1 Injury to blood vessels of thorax, innominate and subclavian arteries
996.1 Mechanical complication of other vascular device, implant, and graft
996.70 Other complications of internal (biological)(synthetic) prosthetic device, implant, and
graft; due to unspecified device, implant, and graft
96.71 Other complications of internal (biological)(synthetic) prosthetic device, implant, and raft; due to heart valve prosthesis
996.72 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to other cardiac device, implant, and graft
996.73 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to renal dialysis device, implant, and graft
996.74 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to other vascular device, implant, and graft
996.75 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to nervous system device, implant and graft
996.76 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to genitourinary device, implant, and graft
996.77 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to internal joint prosthesis
996.78 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to other internal orthopedic device, implant, and graft
996.79 Other complications of internal (biological)(synthetic) prosthetic device, implant, and graft; due to other internal prosthetic device, implant, and graft
997.01 Central nervous system complication
997.02 Iatrogenic cerebrovascular infarction or hemorrhage
997.09 Other nervous system complications
997.1 Cardiac complications
997.2 Peripheral vascular complications
998.0 Postoperative shock
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
998.2 Accidental puncture or laceration during a procedure
93922 – 93931
440.0 Atherosclerosis of aorta
440.21 Atherosclerosis of the extremities with intermittent claudication
440.22 Atherosclerosis of the extremities with rest pain
440.23 Atherosclerosis of the extremities with ulceration
440.24 Atherosclerosis of the extremities with gangrene440.30 Bypass of unspecified graft;
atherosclerosis
440.31 Atherosclerosis of autologous vein bypass graft
440.32 Atherosclerosis of nonautologous biological bypass graft
441.01 Aortic aneurysm and dissection, Thoracic
441.02 Aortic aneurysm and dissection, Abdominal
441.03 Aortic aneurysm and dissection, Thoracoabdominal
441.1 Thoracic aneurysm, ruptured
441.2 Thoracic aneurysm without mention of rupture
441.4 Abdominal aneurysm without mention of rupture
441.6 Thoracoabdominal aneurysm, ruptured
441.7 Thoracoabdominal aneurysm, without mention of rupture
442.3 Aneurysm of artery of lower extremity
443.0 Raynaud’s syndrome
443.81 Peripheral angiopathy in diseases classified elsewhere
443.89 Other specified peripheral vascular diseases
444.0 Arterial embolism and thrombosis of abdominal aorta
444.1 Arterial embolism and thrombosis of thoracic aorta
444.21 Arterial embolism and thrombosis of arteries of the upper extremity
444.22 Arterial embolism and thrombosis of arteries of the lower extremity
444.81 Arterial embolism and thrombosis of iliac artery
444.89 Arterial embolism and thrombosis of other specified artery
447.0 Arteriovenous fistula, acquired
447.1 Stricture of artery
447.2 Rupture of artery
447.8 Other specified disorders of arteries and arterioles
707.10 Ulcer of lower limbs, except decubitus; unspecified
707.11 Ulcer of lower limbs, except decubitus; thigh
707.12 Ulcer of lower limbs, except decubitus; calf
707.13 Ulcer of lower limbs, except decubitus; ankle
707.14 Ulcer of lower limbs, except decubitus; heel and midfoot
707.15 Ulcer of lower limbs, except decubitus; other part of foot
707.19 Ulcer of lower limbs, except decubitus; other part of lower limb
707.8 Chronic ulcer of other specified sites
785.4 Gangrene NOS
903.4 Injury to palmar artery
904.41 Popliteal artery
904.51 Anterior tibial artery
904.52 Anterior tibial vein
904.53 Posterior tibial artery
904.54 Posterior tibial vein
904.6 Deep plantar blood vessels
904.7 Other specified blood vessels of lower extremity
996.1 Mechanical complication of cardiac device implant and graft due to cardiac pacemaker (electrode)
996.71 Due to heart valve prosthesis
996.72 Due to other cardiac device, implant, and graft
996.73 Due to renal dialysis device, implant, and graft
996.74 Due to other vascular device, implant, and graft
997.2 Peripheral vascular complications
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
998.13 Seroma complicating a procedure
998.2 Accidental puncture or laceration during a procedure
93965 – 93971
415.11 Pulmonary embolism and infarction
451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities
451.11 Phlebitis and thrombophlebitis of deep vessels of lower extremities; femoral vein (deep)
(superficial)
451.19 Phlebitis and thrombophlebitis of deep vessels of lower extremities; other
451.81 Phlebitis and thrombophlebitis of iliac vein
451.82 Phlebitis and thrombophlebitis of superficial veins of upper extremities
451.83 Phlebitis and thrombophlebitis of deep veins of upper extremities
451.84 Phlebitis and thrombophlebitis of upper extremities, unspecified
451.89 Phlebitis and thrombophlebitis of unspecified site
454.0 Varicose veins of lower extremities with ulcer
454.2 Varicose veins of lower extremities with inflammation
459.1 Postphlebitic syndrome
459.2 Compression of vein
671.00 Venous complications in pregnancy and the puerperium, varicose veins of legs, unspecified as to episode of care or not applicable
671.01 Venous complications in pregnancy and the puerperium, varicose veins of legs, delivered, with or without mention of antepartum condition
671.02 Venous complications in pregnancy and the puerperium, varicose veins of legs, delivered, with mention of postpartum complication
671.03 Venous complications in pregnancy and the puerperium, varicose veins of legs, antepartum condition or complication
671.04 Venous complications in pregnancy and the puerperium, varicose veins of legs, postpartum condition or complication
671.20 Venous complications in pregnancy and the puerperium, superficial thrombophlebitis, unspecified as to episode of care or not applicable
671.21 Venous complications in pregnancy and the puerperium, superficial thrombophlebitis, delivered, with or without mention of antepartum condition
671.22 Venous complications in pregnancy and the puerperium, superficial thrombophlebitis, delivered, with mention of postpartum complication
671.23 Venous complications in pregnancy and the puerperium, superficial thrombophlebitis, antepartum condition or complication
671.24 Venous complications in pregnancy and the puerperium, superficial thrombophlebitis, postpartum condition or complication
671.30 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, antepartum, unspecified as to episode of care or not applicable
671.31 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, antepartum, delivered, with or without mention of antepartum condition
671.32 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, antepartum, delivered, with mention of postpartum complication
671.33 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, antepartum, antepartum condition or complication
671.34 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, antepartum, postpartum condition or complication
671.40 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, postpartum, unspecified as to episode of care or not applicable
671.41 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, postpartum, delivered, with or without mention of antepartum condition
671.42 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, postpartum, delivered, with mention of postpartum complication
671.43 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, postpartum, antepartum condition or complication
671.44 Venous complications in pregnancy and the puerperium, deep phlebothrombosis, postpartum, postpartum condition or complication
695.9 Unspecified erythematous condition
707.1 Keratoderma, acquired
729.5 Pain in limb
729.81 Swelling of limb
47.61 Gastrointestinal vessel anomaly
747.63 Upper limb vessel anomaly
747.64 Lower limb vessel anomaly
747.69 Anomalies of other specified sites of peripheral vascular system
782.2 Localized superficial swelling, mass, or lump
782.3 Edema
785.4 Gangrene
786.00 Respiratory abnormality, unspecified
786.09 Other symptoms involving respiratory system and other chest symptoms
786.3 Hemoptysis
786.59 Other chest pain, discomfort, pressure or tightness
903.00 Injury to blood vessels of upper extremity, axillary vessel(s), unspecified
903.01 Injury to blood vessels of upper extremity, axillary artery
903.02 Injury to blood vessels of upper extremity, axillary vein
903.1 Injury to blood vessels of upper extremity, brachial blood vessels
903.2 Injury to blood vessels of upper extremity, radial blood vessels
903.4 Injury to blood vessels of upper extremity, palmar artery
903.5 Injury to blood vessels of upper extremity, digital blood vessels
903.8 Injury to blood vessels of upper extremity, other specified blood vessels of upper
extremity
904.0 Injury to blood vessels of lower extremity and unspecified sites, common femoral artery
904.1 Injury to blood vessels of upper extremity, superficial femoral artery
904.2 Injury to blood vessels of upper extremity, femora veins
904.3 Injury to blood vessels of upper extremity, saphenous veins
904.40 Injury to blood vessels of upper extremity, popliteal vessel(s), unspecified
904.41 Injury to blood vessels of upper extremity, popliteal artery
904.42 Injury to blood vessels of upper extremity, popliteal vein
904.50 Injury to blood vessels of upper extremity, tibial vessel(s), unspecified
904.51 Injury to blood vessels of upper extremity, anterior tibial artery
904.52 Injury to blood vessels of upper extremity, anterior tibial vein
904.53 Injury to blood vessels of upper extremity, posterior tibial artery
904.54 Injury to blood vessels of upper extremity, posterior tibial vein
904.6 Injury to blood vessels of upper extremity, deep plantar blood vessels
904.7 Injury to blood vessels of upper extremity, other specified blood vessels of lower
extremity
996.1 Mechanical complication of other vascular device, implant, and graft
996.71 Other complications of internal prosthetic device, implant, and graft due to hear valve prosthesis
996.72 Other complications of internal prosthetic device, implant, and graft due to other cardiac device, implant and graft
996.73 Other complications of internal prosthetic device, implant, and graft due to renal dialysis device, implant, and graft
996.77 Other complications of internal prosthetic device, implant, and graft due to internal joint prosthesis
996.78 Other complications of internal prosthetic device, implant, and graft due to other internal orthopedic device, implant, and graft
996.79 Other complications of internal prosthetic device, implant, and graft due to other internal prosthetic device, implant, and graft
997.01 Central nervous system complication
997.02 Iatrogenic cerebrovascular infarction or hemorrhage
997.09 Other nervous system complications
997.1 Cardiac complications
997.2 Peripheral vascular complications
998.2 Accidental puncture or laceration during a procedure
999.2 Other vascular complications
V12.51 Venous thrombosis and embolism
V12.52 Thrombophlebitis
V72.83 Other specified pre-operative examination
93975 & 93976
185 Malignant neoplasm of testis
239.5 Neoplasms of unspecified nature, other genitourinary organs
440.1 Atherosclerosis of renal artery
441.02 Aortic aneurysm and dissection, abdominal
441.03 Aortic aneurysm and dissection, thoracoabdominal
441.3 Abdominal aneurysm, ruptured
441.4 Abdominal aneurysm without mention of rupture
441.6 Thoracoabdominal aneurysm, ruptured
441.7 Thoracoabdominal aneurysm, without mention of rupture
442.2 Other aneurysm, of iliac artery
442.83 Aneurysm of other specified artery, splenic artery
442.84 Aneurysm of other specified artery, other visceral artery
444.0 Arterial embolism and thrombosis of abdominal aorta
444.81 Arterial embolism and thrombosis, iliac artery
447.1 Stricture of artery
447.3 Hyperplasia of renal artery
447.4 Celiac artery compression syndrome
451.81 Phlebitis and thrombophlebitis, iliac vein
452 Portal vein thrombosis
453.0 Budd-Chiari syndrome
453.2 Other venous embolism and thrombosis of vena cava
453.3 Other venous embolism and thrombosis of renal vein
453.8 Other venous embolism and thrombosis of other specified veins
456.5 Varicose veins of other sites, pelvic varices
593.81 Vascular disorders of kidney
607.82 Vascular disorders of penis
608.83 Edema of penis
747.49 Other anomalies of great veins
747.5 Absence of hypoplasia of umbilical artery
747.61 Gastrointestinal vessel anomaly
747.62 Renal vessel anomaly
747.69 Anomalies of other specified sites of peripheral vascular system
747.82 Spinal vessel anomaly
902.10 Injury to blood vessels of abdomen and pelvis, inferior vena cava, unspecified
902.11 Injury to blood vessels of abdomen and pelvis, hepatic veins
902.19 Other injury to blood vessels of abdomen and pelvis
902.20 Injury to blood vessels of abdomen and pelvis, celiac and mesenteric arteries,
unspecified
902.21 Injury to blood vessels of abdomen and pelvis, gastric artery
902.22 Injury to blood vessels of abdomen and pelvis, hepatic artery
902.23 Injury to blood vessels of abdomen and pelvis, splenic artery
902.24 Injury to blood vessels of abdomen and pelvis, other specified branches of celiac axis
902.25 Injury to blood vessels of abdomen and pelvis, Superior mesenteric artery (trunk)
902.26 Injury to blood vessels of abdomen and pelvis, primary branches of superior mesenteric
artery
902.27 Injury to blood vessels of abdomen and pelvis, inferior mesenteric artery
902.29 Injury to blood vessels of abdomen and pelvis, other
902.31 Injury to blood vessels of abdomen and pelvis, superior mesenteric vein and primary subdivisions
902.32 Injury to blood vessels of abdomen and pelvis, inferior mesenteric vein
902.33 Injury to blood vessels of abdomen and pelvis, portal vein
902.34 Injury to blood vessels of abdomen and pelvis, splenic vein
902.39 Injury to blood vessels of abdomen and pelvis, other
902.41 Injury to blood vessels of abdomen and pelvis, renal artery
902.42 Injury to blood vessels of abdomen and pelvis, renal vein
902.49 Injury to blood vessels of abdomen and pelvis, other
902.51 Injury to blood vessels of abdomen and pelvis, hypogastric artery
902.52 Injury to blood vessels of abdomen and pelvis, hypogastric vein
902.53 Injury to blood vessels of abdomen and pelvis, Iliac artery
902.54 Injury to blood vessels of abdomen and pelvis, iliac vein
902.55 Injury to blood vessels of abdomen and pelvis, uterine artery
902.56 Injury to blood vessels of abdomen and pelvis, uterine vein
902.59 Injury to blood vessels of abdomen and pelvis, other
902.81 Injury to blood vessels of abdomen and pelvis, ovarian artery
902.82 Injury to blood vessels of abdomen and pelvis, ovarian vein
902.87 Injury to blood vessels of abdomen and pelvis, multiple blood vessels of abdomen and pelvis
902.89 Injury to blood vessels of abdomen and pelvis, other
908.4 Late effect of injury to blood vessel of thorax, abdomen, and pelvis
996.1 Mechanical complication of other vascular device, implant, and graft
996.56 Mechanical complication of other vascular device, implant, and graft due to peritoneal dialysis catheter
996.62 Infection and inflammatory reaction due to internal prosthetic device, implant, and graft due to other vascular device, implant, and graft
996.74 Other complications of internal prosthetic device, implant, and graft due to other vascular device, implant, and graft
93978 & 93979
414.02 Coronary atherosclerosis of autologous vein bypass graft
414.03 Coronary atherosclerosis of non-autologous biological bypass graft
414.04 Coronary atherosclerosis of artery bypass graft
414.05 Coronary atherosclerosis of unspecified type of bypass graft
440.0 Atherosclerosis of aorta
440.1 Atherosclerosis of renal artery
441.01 Aortic aneurysm and dissection, thoracic
441.02 Aortic aneurysm and dissection, abdominal
441.03 Aortic aneurysm and dissection, thoracoabdominal
441.2 Thoracic aneurysm without mention of rupture
441.3 Abdominal aneurysm, ruptured
441.4 Abdominal aneurysm without mention of rupture
441.6 Thoracoabdominal aneurysm, ruptured
441.7 Thoracoabdominal aneurysm, ruptured
442.1 Other aneurysm of renal artery
442.2 Other aneurysm of iliac artery
442.83 Other aneurysm of splenic artery
442.84 Other aneurysm, other visceral artery
444.0 Arterial embolism and thrombosis of abdominal aorta
444.1 Arterial embolism and thrombosis of thoracic aorta
444.81 Arterial embolism and thrombosis, Iliac artery
447.1 Stricture of artery
447.3 Hyperplasia of renal artery
447.4 Celiac artery compression syndrome
593.81 Vascular disorders of kidney
747.10 Coarctation of aorta (preductal) (postductal)
747.11 Interruption of aortic arch
747.22 Atresia and stenosis of aorta
747.40 Anomaly of great veins, unspecified
747.49 Other anomalies of great veins
901.0 Injury to blood vessels of thorax, thoracic aorta
902.1 Injury to blood vessels of abdomen and pelvis, inferior vena cava
902.19 Injury to blood vessels of abdomen and pelvis, inferior vena cava, other
902.29 Injury to blood vessels of abdomen and pelvis, celiac and mesenteric arteries, other
902.51 Injury to blood vessels of abdomen and pelvis, hypogastric artery
902.52 Injury to blood vessels of abdomen and pelvis, hypogastric vein
902.53 Injury to blood vessels of abdomen and pelvis, iliac artery
902.54 Injury to blood vessels of abdomen and pelvis, iliac vein
902.55 Injury to blood vessels of abdomen and pelvis, uterine artery
902.56 Injury to blood vessels of abdomen and pelvis, uterine vein
902.59 Injury to blood vessels of abdomen and pelvis, other
908.4 Late effect of injury to blood vessel of thorax, abdomen, and pelvis
996.03 Mechanical complication of cardiac device, implant, and graft due to coronary bypass
graf
996.62 Infection and inflammatory reaction due to internal prosthetic device, implant, and graft due to other vascular device, implant, and graft
996.74 Other complications of internal prosthetic device, implant, and graft due to other vascular device, implant, and graft
996.73 Other complications of internal prosthetic device, implant, and graft due to renal dialysis device, implant, and graft
93980 & 93981
606.8 Infertility due to extratesticular causes
607.3 Disorders of penis, priapism
607.82 Vascular disorders of penis
607.84 Impotence of organic origin
608.83 Vascular disorders
93990
996.73 Other complications of internal prosthetic device, implant, and graft due to renal dialysis device, implant, and graft

Note: Diagnostic codes are to be used at their highest level of specificity. Fourth and fifth digits
should be utilized when they are available.

Reason(s) for Denial:

There is no literature to support the efficacy of this procedure for any indications other than those listed.

Non-Covered ICD-9-CM Code(s):

All others not listed above.

Coding Guidelines:

This policy should not be utilized for complete and/or detailed coding instructions. Appropriate and accepted materials such as the most current International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and levels, 1,2, and 3 of the Health Care Financing Administration, Common Procedural Coding System (HCPCS) should be referenced accordingly for coding of services submitted for reimbursement.

EMC and hard copy claims will be monitored for appropriateness and frequency.

A duplex scan includes a real-time scan (see CPT manual; Diagnostic Ultrasound). Consequently, billing for both a duplex scan and echography of the same body part represents unbundling and is not allowed.

76936 Ultrasound guided compression repair of arterial pseudo-aneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation, compression of lesion and imaging)

93875 Noninvasive physiological studies of extracranial arteries, complete bilateral study (e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

93880 Duplex scan of extracranial arteries: complete bilateral study

93882 Unilateral or limited study

93886 Transcranial Doppler study of the intracranial arteries; complete study

93888 Limited study

93922 Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement)

93923 Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia)

93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study

93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study

93926 Unilateral or limited study

93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study

93931 Unilateral or limited study

93965 Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers phleborrheograph, impedance plethysmography)

93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

93971 Unilateral or limited study

93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, and/or retroperitoneal organs; complete study

93976 Limited study

93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

93979 Unilateral or limited study

93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study

93981 Follow-up or limited study

93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow)

Documentation Requirements:

Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim. Claims submitted without such evidence will be denied as not being medically necessary.

Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the provider to maintain documentation of medical necessity for postpayment audit.

Payments can be made on a review basis for diagnosis other than those listed above. The setting and need for these services must be documented to be:

1. Safe and effective
2. Appropriate for the diagnosis
3. Not for convenience
4. A need not met by a service previously performed

Documentation should include but is not limited to:

1. Peer reviewed medical literature
2. AMA DATTA reports
3. Policy of specialty groups
4. Progress notes

Other Comments:

Due to a request from the MS Radiological Society, the effective date for implementation of required certification for technologist will be delayed until July 1, 1998. The effective date of the remainder of this policy is noted below.

This policy will be utilized in conducting both prepayment and postpayment reviews.

Sources of Information and Basis for Decision:

1. Physicians’ Current Procedural Terminology 2001.

2. International Classification of Diseases, 9th Revision, Clinical Modification, Practice Management Information Corporation [PMIC] 2001.

3. Medicare Carrier Manual, Appendix, Coverage Issues-Diagnostic Services, Coverage Issues 50-6.

4. Federal Register, Volume 57, Number 25, Friday, November 20, 1992.

5. Strandness, D.E.; Andros,G; Baker, J.D.; Berstein, E.F.; " Vascular Laboratory Utilization and Payment: Report of the Ad Hoc Committee of the Western Vascular Society." J. Vasc Surg 1992; 16:162169.

6. "Assessment: Transcranial Doppler." Report of the American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee. Neurology 1990; 40:680.1

7. "Endarterectomy for a Symptomatic Carotid Artery Stenosis." JAMA 1995, 273:1421-1428

8. Chimowitz, M.I., Kokkinos, J., Strong, J.; Brown, M.B.; Levine, S.R., Silliman, S.; Pessin, M.S.; Weichel, E.; Sila, C.A.; Furlan, A.J.; Kargman, D.E.; Sacco, R.L.;Wityk, R.J.; Ford, G.;Fayad, P.B. "The Warfarin-Aspirin Symptomatic Intracranial Disease Steady." Neurology 1995:45:1488- 1493.

9. Carrier Program Memorandum Transmittal N01-28. Change Request 850. April 19, 2001.

Carrier Advisory Committee Notes:

This policy does not reflect the sole opinion of the Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from:

Medical Specialty Societies

Mississippi State Medical Association

Information and Quality Health Care

This policy was discussed at the 10/08/1997 CAC meeting.

Start Date of Comment Period:

10/08/1997

Start Date of Notice Period:

01/01/1998

Revision History:

Revision Number: 03, 02, 01

Revision Date: 09/2002, 08/21/2001, 06/01/2001

This policy was updated October 2001 by expanding ICD-9-CM codes to the 5th digit and adding national coverage provided to carriers in Transmittal AB-01-129; Change Request #1855.

This policy was revised August 2001 to include ICD-9 code 362.34 for CPT codes 93875-93888. This policy was revised to omit reference to specific credentialing agencies. Direct physician supervision was noted as an acceptable condition for performing these services.

Truncated ICD-9 codes 443, 449, and 451 were deleted and replaced with codes 443.0, 443.1, 443.81, 443.89, 444.0, 444.1, 444.21, 444.22, 444.81, 444.89, 451.0, 451.11, 451.19, 451.81, 451.82, 451.83, 451.84, and 451.89. Deleted CPT codes 93920 and 93921 were removed from this policy.

The appropriate supervision level for CPT code 76936 was noted as personal supervision according to Change Request 850, April 19, 2001.

This policy was updated Sept 2002 by adding V72.83 as a covered ICD-9 code.

This page was last updated on  09/05/03 .