L28828-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Duplex Scan of Hemodialysis Access (L28828)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28828

LCD Title Duplex Scan of Hemodialysis Access

Contractor's Determination Number A93990

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date ANTICIPATED 10/08/2012

Revision Effective Date

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Chapter 11, Section 20.1

Indications and Limitations of Coverage and/or Medical Necessity

Duplex scanning is 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. This technique allows sampling of a particular imaged blood vessel with analysis of the blood flow velocity.

Evaluation of endogenous arteriovenous fistulae and synthetic polytetrafluoroethylene (PTFE) grafts, which are the two principal means of creating permanent vascular access for hemodialysis, can be achieved by duplex scanning.

Limited coverage has been established for diagnostic 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 and symptoms of possible failure of the access site, and when the results of the procedures will permit medical intervention to address the problem. However, other diagnostic vascular services, such as venography, would be considered duplicative services and would not be covered by Medicare.

Appropriate indications for duplex scan of hemodialysis access site would include clear documentation in the dialysis record of signs of chronic (i.e., 3 successive dialysis sessions) abnormal function, including:

I. Clinical Indicators

- difficult canulation by multiple personnel;

- thrombus aspiration by multiple personnel;

- prolonged bleeding after needle withdrawal;

- pain in graft arm;

- persistent swelling in graft arm;

- elevated dynamic venous pressure greater than 200 mm Hg when measured during dialysis with the blood pump seton a 200 cc/min;

- access recirculation time of 12% or greater;

- an otherwise unexplained urea reduction ratio of less than 60%; or

- shunt collapse, suggesting poor arterial flow.

II. Physical Findings by Examination of Graft

- bruit is discontinuous, systolic only, harsh, high pitched;

- thrill is at stenotic sites, possibly multiple, discontinuous, systolic only; and/or

- an access with a palpable “water hammer” pulse on examination, (which implies venous outflow obstruction).

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only)

013x Hospital Outpatient

021x Skilled Nursing - Inpatient (Including Medicare Part A)

022x Skilled Nursing - Inpatient (Medicare Part B only)

023x Skilled Nursing - Outpatient

072x Clinic - Hospital Based or Independent Renal Dialysis Center

085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0920 Other Diagnostic Services - General Classification

0921 Other Diagnostic Services - Peripheral Vascular Lab

0929 Other Diagnostic Services - Other Diagnostic Service

CPT/HCPCS Codes

93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW)

ICD-9 Codes that Support Medical Necessity

996.73 OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the facility and/or physician must clearly indicate the medical necessity of the services being billed. The documentation must also indicate that the service was performed. This information is normally included in the office/progress notes, facility/hospital records, and/or procedure report.

Appendices

Utilization Guidelines

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, or venogram), but not both.

Sources of Information and Basis for Decision

American Journal of Kidney Diseases. (2001). Volume 37,1. WB Saunders Company.

Society of Interventional Radiology. (2004). Preservation of Hemodialysis Access. Retrieved from the internet on October 20, 2005 from http://www.sirweb.org.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from various societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:N/A

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28828) replaces LCD L1094 as the policy in notice. This document (L28828) is effective on 02/16/2009.

8/1/2010 - The description for Bill Type Code 12 was changed 8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 72 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0920 was changed 8/1/2010 - The description for Revenue code 0921 was changed 8/1/2010 - The description for Revenue code 0929 was changed

Reason for Change