LCD/NCD Portal

L28828 DUPLEX SCAN OF HEMODIALYSIS ACCESS

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

 

10/08/12

 

• 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:

o In the presence of signs and symptoms of possible failure of the access site.

o 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:

o 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 set on a 200 cc/min.

 Access recirculation time of 12% or greater.

 An otherwise unexplained urea reduction ratio of less than 60%.

 Shunt collapse, suggesting poor arterial flow.

o Physical Findings by Examination of Graft:

 Bruit is discontinuous, systolic only, harsh, high pitched.

 Thrill is at stenotic sites, possibly multiple, discontinuous, systolic only.

 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.

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

72x Clinic - Hospital Based or Independent Renal Dialysis Center

85x 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

 

 

Documentation 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.

 

 

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.

 

 

Treatment Logic

 

• 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.

 

 

Sources of Information and Basis for Decision

 

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

 

FCSO LCD 28828, Duplex Scan of Hemodialysis Access, 10/08/12. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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

 

 

AMA CPT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

CMS LCD DUPLEX SCAN OF HEMODIALYSIS ACCESS