LCD/NCD Portal

Automated World Health

L28829 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES

 

 

01/31/2012

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• Noninvasive peripheral arterial studies include two types of testing, noninvasive physiologic studies and duplex scans.

o Noninvasive physiologic studies are functional measurement procedures that include:

 Doppler ultrasound studies.

 Blood pressure measurements.

 Transcutaneous oxygen tension measurements.

 Plethysmography.

o A complete extremity physiologic study includes:

 Pressure measurements.

And

 An additional physiologic technique.

 Doppler ultrasound study.

 Plethysmography.

• Plethysmography implies volume measurement procedures including air impedance or strain gauge methods.

o Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part.

• Noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner.

o Duplex scanning combines the information provided by two-dimensional imaging with pulsed-wave Doppler techniques which allows analysis of the blood flow velocity.

• 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 with analysis of all data, including bidirectional vascular flow or imaging when provided.

o The display may be a two-dimensional image with spectral analysis and color flow or a plethysmographic recording that allows for quantitative analysis.

 

 

Indications

 

• In general, noninvasive arterial studies are indicated when endovascular or other invasive correction is contemplated, but not to follow noninvasive medical treatment regimens or to monitor unchanged symptomatology.

o The latter may be followed with physical findings, including Ankle/Brachial Indices (ABIs), and/or progression or relief of signs and/or symptoms.

• Duplex scanning of the lower extremity arteries performed to establish the level and/or degree of arterial occlusive disease, will be considered medically necessary if:

o Significant signs and/or symptoms indicate a high likelihood of limb ischemia.

o the patient is a candidate for invasive therapeutic procedures under any of the following circumstances:

 The patient has symptoms of peripheral vascular ischemia and is found on physical examination to have absence or marked diminution of pulses (suspected to be secondary to obstruction of lower extremity arteries) of one or both lower extremities.

 The patient has developed sudden pallor, numbness, and coolness of an extremity and vascular obstruction (embolism or thrombosis) is suspected.

 Claudication of less than one block or of such severity that it interferes significantly with the patient's occupation or lifestyle.

 The patient has an aneurysm or arteriovenous malformation of a lower extremity artery.

 The patient has sustained lower extremity trauma with possible vascular injury or the patient has sustained iatrogenic vascular injury.

 Rest pain of ischemic origin (typically including the forefoot), 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 pre-gangrenous changes of the extremity, or ischemic ulceration of the extremity occurring in the absence of pulses.

• Follow-up studies post-operative conditions:

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

o Following bypass surgery or post-angioplasty with or without stent placement at three months, six months and one year when clinically indicated.

o Subsequent studies may be allowed if:

 There is clinical evidence of recurrent vascular disease evidenced by signs.

 Decreased ABI from previous exam.

 Symptoms.

 Recurrence of claudication symptoms that interfere significantly with the patient’s occupation or lifestyle.

 For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

 

 

Limitations

 

• 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.

o 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.

 Lack of toe nail growth.

o Unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

• An ABI is NOT a separately reimbursable procedure when performed by itself and would be considered part of the physical examination.

o When the ABI is abnormal (i.e., <0.9 at rest), it must be accompanied by another appropriate indication before proceeding to more sophisticated or complete studies, except in patients with severely elevated ankle blood pressure.

• Examples of additional signs and symptoms that do NOT indicate medical necessity include:

o Continuous burning of the feet is considered to be a neurologic symptom.

o "Leg pain, nonspecific" or "Pain in limb" as single diagnoses are too general to warrant further investigation unless they can be related to other signs and symptoms.

o 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.

o Absence of relatively minor pulses (e.g., dorsalis pedis or posterior tibial) in the absence of ischemic symptoms.

 The absence of pulses is NOT an indication to proceed beyond the physical examination unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

o Screening of an asymptomatic patient is NOT covered by Medicare.

• In general, non-invasive studies of the arterial system are to be utilized when invasive correction is contemplated, but not to follow non-invasive medical treatment regimens (e.g., to evaluate pharmacologic intervention) or to monitor unchanged symptomatology.

o The latter may be followed with physical findings including ABIs and/or progression or relief of signs and/or symptoms.

• Noninvasive vascular testing studies are medically necessary only if the outcome will potentially impact the clinical management of the patient.

o For example, if a patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of non-invasive studies, and non-invasive vascular procedures will not provide any unique diagnostic information that would impact patient management, then the non-invasive procedures are not medically necessary.

o If it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not medically necessary.

o It is also expected that the studies are not redundant of other diagnostic procedures that must be performed.

• When an uninterpretable study (i.e., poor quality or not in accordance with regulatory standards) results in performing another type of study, only the successful study should be billed.

o For example, when an uninterpretable non-invasive physiologic study (CPT code 93922, 93923 or 93924) is performed which results in performing a duplex scan (CPT codes 93925 or 93926), only the duplex scan should be billed.

• Noninvasive vascular procedures will not be covered when performed based on internal protocols of the testing facility; a referral for one noninvasive study is not a blanket referral for all studies.

o Each procedure must be specifically ordered by the physician/nonphysician practitioner treating the patient and the medical necessity criteria specified in this LCD must be met.

• Typically, it is appropriate for follow-up studies post-angioplasty, with or without stent placement to be performed at three months, six months and one year.

o Subsequent studies may be allowed if there is clinical evidence of recurrent vascular disease evidenced by signs (i.e. decreased ABI from previous exam) or symptoms (i.e. recurrence of claudication).

o For postoperative surveillance, either a limited Duplex or multi-level Doppler with pressures is usually sufficient, but it is not considered necessary to do both.

• Performance of both a physiological test (93922, 93923, 93924) and duplex scanning (93925, 93926) of extremity arteries during the same encounter would not generally be expected.

o Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

o Note: Reimbursement of physiologic testing will not be allowed after a duplex scan has been performed.

• 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.

o Consequently, documentation must clearly support the medical necessity of both procedures if performed during the same encounter.

• Performance of both non-invasive extracranial arterial studies (CPT code 93880 or 93881) and non-invasive evaluation of extremity arteries (CPT code 93925 or 93926) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected.

o Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

• The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported (CPT 2005, page 370).

o The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure.

o If an examination is performed with hand-carried equipment, the quality of the exam, printout, and report must be in keeping with accepted national standards.

 

 

TRAINING REQUIREMENTS

 

• The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill and experience of the technologist and the physician performing the interpretation of the study.

o Consequently, the technologist and the physician must maintain proof of training and experience.

• All non-invasive vascular diagnostic studies must be:

o Performed by a qualified physician.

o Performed under the general supervision of a qualified physician by a technologist who has demonstrated minimum entry level competency by being credentialed in vascular technology.

o Performed in a laboratory accredited in vascular technology.

• Examples of certification in vascular technology for non-physician personnel include:

o Registered Vascular Technologist (RVT) credential.

o Registered Vascular Specialist (RVS) credential.

• These credentials must be provided by nationally recognized credentialing organizations such as:

o The American Registry of Diagnostic Medical Sonographers (ARDMS) which provides RDMS and RVT credentials.

o The Cardiovascular Credentialing International (CCI) which provides RVS credential.

• Appropriate nationally recognized laboratory accreditation bodies include:

o Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

o American College of Radiology (ACR).

• General Supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

o Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

• Note: In accordance with 42 CFR 410.33, noninvasive vascular studies performed in an Independent Diagnostic Testing Facility (IDTF) include credentialing requirements that supersede those above.

o Noninvasive vascular studies performed in an IDTF must follow the supervision and credentialing guidelines set forth in the LCD for Independent Diagnostic Testing Facility (IDTF).

• Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials.

o However, services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

• As published in the CMS online manual publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1:

o In order to be covered under Medicare, a service shall be reasonable and necessary.

o When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under 1862(a)(1)(A).

o Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

 Safe and effective.

 Not experimental or investigational. (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000 which meet the requirements of the Clinical Trials NCD are considered reasonable and necessary);

 Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

 Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

 Furnished in a setting appropriate to the patient's medical needs and condition

 Ordered and furnished by qualified personnel.

 One that meets, but does not exceed, the patient's medical need.

 At least as beneficial as an existing and available medically appropriate alternative.

 

 

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

14x Hospital - Laboratory Services Provided to Non-patients

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

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

23x Skilled Nursing - Outpatient

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

 

93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY

93926 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY

 

 

ICD-9 Codes that Support Medical Necessity

 

440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION

440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN

440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION

440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

440.4 CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES

442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY

443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

444.01 SADDLE EMBOLUS OF ABDOMINAL AORTA

444.09 OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA

444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

447.0 ARTERIOVENOUS FISTULA ACQUIRED

447.1 STRICTURE OF ARTERY

449 SEPTIC ARTERIAL EMBOLISM

782.0 DISTURBANCE OF SKIN SENSATION

785.9 OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM

820.00 FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED

820.01 FRACTURE OF EPIPHYSIS (SEPARATION) (UPPER) OF NECK OF FEMUR CLOSED

820.02 FRACTURE OF MIDCERVICAL SECTION OF FEMUR CLOSED

820.03 FRACTURE OF BASE OF NECK OF FEMUR CLOSED

820.09 OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED

820.10 FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR OPEN

820.11 FRACTURE OF EPIPHYSIS (SEPARATION) (UPPER) OF NECK OF FEMUR OPEN

820.12 FRACTURE OF MIDCERVICAL SECTION OF FEMUR OPEN

820.13 FRACTURE OF BASE OF NECK OF FEMUR OPEN

820.19 OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN

820.20 FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR CLOSED

820.21 FRACTURE OF INTERTROCHANTERIC SECTION OF FEMUR CLOSED

820.22 FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR CLOSED

820.30 FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN

820.31 FRACTURE OF INTERTROCHANTERIC SECTION OF FEMUR OPEN

820.32 FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN

820.8 FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR CLOSED

820.9 FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN

821.00 FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED

821.01 FRACTURE OF SHAFT OF FEMUR CLOSED

821.10 FRACTURE OF UNSPECIFIED PART OF FEMUR OPEN

821.11 FRACTURE OF SHAFT OF FEMUR OPEN

821.20 FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART CLOSED

821.21 FRACTURE OF FEMORAL CONDYLE CLOSED

821.22 FRACTURE OF LOWER EPIPHYSIS OF FEMUR CLOSED

821.23 SUPRACONDYLAR FRACTURE OF FEMUR CLOSED

821.29 OTHER FRACTURE OF LOWER END OF FEMUR CLOSED

821.30 FRACTURE OF LOWER END OF FEMUR UNSPECIFIED PART OPEN

821.31 FRACTURE OF FEMORAL CONDYLE OPEN

821.32 FRACTURE OF LOWER EPIPHYSIS OF FEMUR OPEN

821.33 SUPRACONDYLAR FRACTURE OF FEMUR OPEN

821.39 OTHER FRACTURE OF LOWER END OF FEMUR OPEN

822.0 CLOSED FRACTURE OF PATELLA

822.1 OPEN FRACTURE OF PATELLA

823.00 CLOSED FRACTURE OF UPPER END OF TIBIA

823.01 CLOSED FRACTURE OF UPPER END OF FIBULA

823.02 CLOSED FRACTURE OF UPPER END OF FIBULA WITH TIBIA

823.10 OPEN FRACTURE OF UPPER END OF TIBIA

823.11 OPEN FRACTURE OF UPPER END OF FIBULA

823.12 OPEN FRACTURE OF UPPER END OF FIBULA WITH TIBIA

823.20 CLOSED FRACTURE OF SHAFT OF TIBIA

823.21 CLOSED FRACTURE OF SHAFT OF FIBULA

823.22 CLOSED FRACTURE OF SHAFT OF FIBULA WITH TIBIA

823.30 OPEN FRACTURE OF SHAFT OF TIBIA

823.31 OPEN FRACTURE OF SHAFT OF FIBULA

823.32 OPEN FRACTURE OF SHAFT OF FIBULA WITH TIBIA

823.40 TORUS FRACTURE OF TIBIA ALONE

823.41 TORUS FRACTURE OF FIBULA ALONE

823.42 TORUS FRACTURE OF FIBULA WITH TIBIA

823.80 CLOSED FRACTURE OF UNSPECIFIED PART OF TIBIA

823.81 CLOSED FRACTURE OF UNSPECIFIED PART OF FIBULA

823.82 CLOSED FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA

823.90 OPEN FRACTURE OF UNSPECIFIED PART OF TIBIA

823.91 OPEN FRACTURE OF UNSPECIFIED PART OF FIBULA

823.92 OPEN FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA

824.0 FRACTURE OF MEDIAL MALLEOLUS CLOSED

824.1 FRACTURE OF MEDIAL MALLEOLUS OPEN

824.2 FRACTURE OF LATERAL MALLEOLUS CLOSED

824.3 FRACTURE OF LATERAL MALLEOLUS OPEN

824.4 BIMALLEOLAR FRACTURE CLOSED

824.5 BIMALLEOLAR FRACTURE OPEN

824.6 TRIMALLEOLAR FRACTURE CLOSED

824.7 TRIMALLEOLAR FRACTURE OPEN

824.8 UNSPECIFIED FRACTURE OF ANKLE CLOSED

824.9 UNSPECIFIED FRACTURE OF ANKLE OPEN

825.0 FRACTURE OF CALCANEUS CLOSED

825.1 FRACTURE OF CALCANEUS OPEN

825.20 FRACTURE OF UNSPECIFIED BONE(S) OF FOOT (EXCEPT TOES) CLOSED

825.21 FRACTURE OF ASTRAGALUS CLOSED

825.22 FRACTURE OF NAVICULAR (SCAPHOID) BONE OF FOOT CLOSED

825.23 FRACTURE OF CUBOID BONE CLOSED

825.24 FRACTURE OF CUNEIFORM BONE OF FOOT CLOSED

825.25 FRACTURE OF METATARSAL BONE(S) CLOSED

825.29 OTHER FRACTURE OF TARSAL AND METATARSAL BONES CLOSED

825.30 FRACTURE OF UNSPECIFIED BONE(S) OF FOOT (EXCEPT TOES) OPEN

825.31 FRACTURE OF ASTRAGALUS OPEN

825.32 FRACTURE OF NAVICULAR (SCAPHOID) BONE OF FOOT OPEN

825.33 FRACTURE OF CUBOID BONE OPEN

825.34 FRACTURE OF CUNEIFORM BONE OF FOOT OPEN

825.35 FRACTURE OF METATARSAL BONE(S) OPEN

825.39 OTHER FRACTURES OF TARSAL AND METATARSAL BONES OPEN

827.0 OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB CLOSED

827.1 OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB OPEN

828.0 MULTIPLE FRACTURES INVOLVING BOTH LOWER LIMBS LOWER WITH UPPER LIMB AND LOWER LIMB(S) WITH RIB(S) AND STERNUM CLOSED

828.1 MULTIPLE FRACTURES INVOLVING BOTH LOWER LIMBS LOWER WITH UPPER LIMB AND LOWER LIMB(S) WITH RIB(S) AND STERNUM OPEN

835.00 CLOSED DISLOCATION OF HIP UNSPECIFIED SITE

835.01 CLOSED POSTERIOR DISLOCATION OF HIP

835.02 CLOSED OBTURATOR DISLOCATION OF HIP

835.03 OTHER CLOSED ANTERIOR DISLOCATION OF HIP

835.10 OPEN DISLOCATION OF HIP UNSPECIFIED SITE

835.11 OPEN POSTERIOR DISLOCATION OF HIP

835.12 OPEN OBTURATOR DISLOCATION OF HIP

835.13 OTHER OPEN ANTERIOR DISLOCATION OF HIP

836.0 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.1 TEAR OF LATERAL CARTILAGE OR MENISCUS OF KNEE CURRENT

836.2 OTHER TEAR OF CARTILAGE OR MENISCUS OF KNEE CURRENT

836.3 DISLOCATION OF PATELLA CLOSED

836.4 DISLOCATION OF PATELLA OPEN

836.50 CLOSED DISLOCATION OF KNEE UNSPECIFIED PART

836.51 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.52 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.53 MEDIAL DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.54 LATERAL DISLOCATION OF TIBIA PROXIMAL END CLOSED

836.59 OTHER DISLOCATION OF KNEE CLOSED

836.60 DISLOCATION OF KNEE UNSPECIFIED PART OPEN

836.61 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.62 POSTERIOR DISLOCATION OF TIBIA PROXIMAL END OPEN

836.63 MEDIAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.64 LATERAL DISLOCATION OF TIBIA PROXIMAL END OPEN

836.69 OTHER DISLOCATION OF KNEE OPEN

837.0 CLOSED DISLOCATION OF ANKLE

837.1 OPEN DISLOCATION OF ANKLE

838.00 CLOSED DISLOCATION OF FOOT UNSPECIFIED PART

838.01 CLOSED DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED

838.02 CLOSED DISLOCATION OF MIDTARSAL (JOINT)

838.03 CLOSED DISLOCATION OF TARSOMETATARSAL (JOINT)

838.04 CLOSED DISLOCATION OF METATARSAL (BONE) JOINT UNSPECIFIED

838.05 CLOSED DISLOCATION OF METATARSOPHALANGEAL (JOINT)

838.06 CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) FOOT

838.09 CLOSED DISLOCATION OF OTHER PART OF FOOT

838.10 OPEN DISLOCATION OF FOOT UNSPECIFIED PART

838.11 OPEN DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED

838.12 OPEN DISLOCATION OF MIDTARSAL (JOINT)

838.13 OPEN DISLOCATION OF TARSOMETATARSAL (JOINT)

838.14 OPEN DISLOCATION OF METATARSAL (BONE) JOINT UNSPECIFIED

838.15 OPEN DISLOCATION OF METATARSOPHALANGEAL (JOINT)

838.16 OPEN DISLOCATION OF INTERPHALANGEAL (JOINT) FOOT

838.19 OPEN DISLOCATION OF OTHER PART OF FOOT

904.0 INJURY TO COMMON FEMORAL ARTERY

904.1 INJURY TO SUPERFICIAL FEMORAL ARTERY

904.40 INJURY TO POPLITEAL VESSEL(S) UNSPECIFIED

904.41 INJURY TO POPLITEAL ARTERY

904.50 INJURY TO TIBIAL VESSEL(S) UNSPECIFIED

904.51 INJURY TO ANTERIOR TIBIAL ARTERY

904.53 INJURY TO POSTERIOR TIBIAL ARTERY

904.6 INJURY TO DEEP PLANTAR BLOOD VESSELS

904.7 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF LOWER EXTREMITY

904.8 INJURY TO UNSPECIFIED BLOOD VESSEL OF LOWER EXTREMITY

904.9 INJURY TO BLOOD VESSELS OF UNSPECIFIED SITE

924.00 CONTUSION OF THIGH

924.01 CONTUSION OF HIP

924.10 CONTUSION OF LOWER LEG

924.11 CONTUSION OF KNEE

924.20 CONTUSION OF FOOT

924.21 CONTUSION OF ANKLE

924.4 CONTUSION OF MULTIPLE SITES OF LOWER LIMB

924.5 CONTUSION OF UNSPECIFIED PART OF LOWER LIMB

924.8 CONTUSION OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED

924.9 CONTUSION OF UNSPECIFIED SITE

928.00 CRUSHING INJURY OF THIGH

928.01 CRUSHING INJURY OF HIP

928.10 CRUSHING INJURY OF LOWER LEG

928.11 CRUSHING INJURY OF KNEE

928.20 CRUSHING INJURY OF FOOT

928.21 CRUSHING INJURY OF ANKLE

928.8 CRUSHING INJURY OF MULTIPLE SITES OF LOWER LIMB

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 NOT ELSEWHERE CLASSIFIED

V58.49* OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY

* This ICD-9-CM code should be used in conjunction with other aftercare codes to fully identify the reason for the aftercare encounter.

 

 

Documentation Requirements

 

• Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must clearly indicate the medical necessity of duplex scan of lower extremity arteries i.e., signs and symptoms, relevant history (including known diagnoses, and/or prior imaging).

o This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

o Also, the results of the duplex scan of lower extremity arterial studies must be included in the patient's medical record.

o A hard copy or soft copy convertible to a hard copy provides a permanent record of the study performed and must be of a quality that meets accepted medical standards.

• If the provider of duplex scan of lower extremity arterial studies is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies.

• The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available to MAC J9 upon request.

o Non-invasive vascular studies are medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient.

o Providers billing Medicare are encouraged to obtain additional information from referring providers and/or patients or medical records to determine the medical necessity of studies performed.

o Referring physicians are required to provide appropriate diagnostic information to the performing provider.

• Noninvasive vascular procedures will not be covered when performed based on internal protocols of the testing facility; a referral for one non-invasive study is not a blanket referral for all studies.

o The provider treating the patient must specifically order the procedures in writing; an order must be on record for each non-invasive study performed.

• When an uninterpretable study (i.e., poor quality or not in accordance with regulatory standards) results in performing another type of study, only the successful study should be billed.

o For example, when an uninterpretable non-invasive physiologic study (CPT code 93922, 93923 or 93924) is performed which results in performing a duplex scan (CPT codes 93925 or 93926), only the duplex scan should be billed.

• Performance of both a physiological test (93922, 93923, 93924) and duplex scanning (93925, 93926) of extremity arteries during the same encounter would not generally be expected.

o Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

o Note: Reimbursement of physiologic testing will not be allowed after a duplex scan has been performed.

• 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.

o Consequently, documentation must clearly support the medical necessity of both procedures if performed during the same encounter.

• Performance of both non-invasive extracranial arterial studies (CPT code 93880 or 93881) and non-invasive evaluation of extremity arteries (CPT code 93925 or 93926) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected.

o Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

• Documentation must support the criteria for coverage as set forth in the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of this LCD and should reflect how the results of this test will be used in the patient’s plan of care.

• The medical necessity for performing repeat extremity arterial studies must be clearly documented in the medical record.

• Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem.

o Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.

 

 

Utilization Guidelines

 

• Generally, it is NOT expected that these services would be performed more than once in a year, EXCLUDING inpatient hospital (21) and emergency room (23) places of service.

• Note: This LCD imposes utilization guideline limitations. Each patient’s condition and response to treatment must medically warrant the number of services reported for payment.

o Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record.

o It is expected that patients will not routinely require the maximum allowable number of services.

 

 

Treatment Logic

 

• Noninvasive peripheral arterial studies include two types of testing, noninvasive physiologic studies and duplex scans.

• Noninvasive physiologic studies are functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmography.

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

• Plethysmography implies volume measurement procedures including air impedance or strain gauge methods.

• Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part.

• Noninvasive physiologic studies are performed using equipment separate and distinct from the duplex scanner.

• Duplex scanning combines the information provided by two-dimensional imaging with pulsed-wave Doppler techniques which allows analysis of the blood flow velocity.

• 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 with analysis of all data, including bidirectional vascular flow or imaging when provided.

• The display may be a two-dimensional image with spectral analysis and color flow or a plethysmographic recording that allows for quantitative analysis

 

 

Sources of Information and Basis for Decision

 

Abuhamad, A., Benacerraf, B., Woletz, P., Burke, B. (2004). The accreditation of ultrasound practices – Impact on compliance with minimum performance guidelines. J Ultrasound Med, 23, 1023-1029.

 

American College of Radiology. (2007). ACR-AIUM-SIR practice guideline for the performance of physiologic evaluation of extremity arteries. Retrieved from http://www.acr.org/secondarymainmenucategories/quality_safety/guidelines.aspx

 

American College of Radiology. (2009). ACR appropriateness criteria: Follow-up of lower-extremity arterial bypass surgery. Retrieved from http://www.acr.org/ac

 

American College of Radiology. (2009). ACR appropriateness criteria: Recurrent symptoms following lower-extremity angioplasty. Retrieved from http://www.acr.org/ac

 

Davies, A., Hawdon, A., Sydes, M., Thompson, S. (2005). Is duplex surveillance of value after leg vein bypass grafting? Circulation, 112, 1985-1991. doi:10.1161/CIRCULATIONAHA.104.518738. Retrieved from http://circ.ahajournals.org/content/112/13/1985.full.pdf+html

 

FCSO LCD 29158, Duplex Scan Of Lower Extremity Arteries. 01/31/2012. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Hirsch, A., Haskal, Z., Hertzer, N., Bakal, C., Creager, M., Halperin, J., Hiratzka, L., Murphy, W., Olin, J., Puschett, J., Rosenfield, K., Sacks, D., Stanley, J., Taylor Jr., L. White, C., White, J., & White, R. (2006). ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine and Biology, and the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Journal of the American College of Cardiology, 47, e1-e192. doi:10.1016/j.jacc.2006.02.024. Retrieved from http://circ.ahajournals.org/cgi/reprint/113/11/e463.

 

Olin, J., Allie, D., Belkin, M., Bonow, R., Casey Jr., D., Creager, M., Gerber, T., Hirsch, A., Jaff, M., Kaufman, J., Lewis, C., Martin, E., Martin, L., Sheehan, P., Stewart, K., Treat-Jacobson, D., White, C., & Zheng, Z. (2010). ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults with Peripheral Artery Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease). Circulation, 122, 2583-2618. doi:10.1161/CIR.0b013e3182031a3c. Retrieved from http://circ.ahajournals.org/cgi/reprint/122/24/2583

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Other Contractor’s LCDs.

 

Society for Vascular Ultrasound–Professional performance guidelines. (2004). Upper extremity arterial segmental physiologic evaluation. (2003). Lower extremity arterial segmental physiologic evaluation. Retrieved July 8, 2005, from http://www.svunet.org/about/positions.

 

Stanley, D. (2004). The importance of Intersocietal Commission for the accreditation of vascular laboratories (ICAVL) certification for noninvasive peripheral vascular tests: The Tennessee experience. The Journal for Vascular Ultrasound, 28(2), 65-69.

 

United States Government Accountability Office. (2007). Report to congressional committees: Medicare ultrasound procedures-Consideration of payment reforms and technician qualification requirements, GAO-07-734. Retrieved from http://www.gao.gov/new.items/d07734.pdf]

 

 

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 LOWER EXTREMITY ARTERIES

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