L28830-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Duplex Scanning (L28830)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28830

LCD Title Duplex Scanning

Contractor's Determination Number A93975

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

Revision Effective Date

For services performed on or after 10/01/2011

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. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4,

Section 220.5 Hospital Manual, Section 443 Intermediary Manual, Section 3631

Indications and Limitations of Coverage and/or Medical Necessity

Arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs (procedure codes 93975 and 93976)

Medicare may provide coverage for duplex scanning of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs (procedure codes 93975 and 93976) ]when performed for the following indications:

• To evaluate patients presenting with signs or symptoms such as epigastric or periumbilical postprandial pains that last for 1-3 hours and/or with associated weight loss resulting from decreased oral intake which may indicate chronic intestinal ischemia.

• To evaluate patients presenting with an acute onset of crampy or steady epigastric and periumbilical abdominal pain combined with minimal or no findings on abdominal examination and a high leukocyte count to rule out acute intestinal ischemia.

• To evaluate a patient who has sustained trauma to the abdominal, pelvic and/or retroperitoneal area resulting in a possible injury to the arterial inflow and/or venous outflow of the abdominal, pelvic and/or retroperitoneal organs.

• To evaluate a suspicion of an aneurysm of the renal artery or other visceral artery based on a patient’s signs and symptoms of abdominal pain or noted as an incidental finding on another radiological examination.

• To evaluate a hypertensive patient who has failed first line antihypertensive drug therapy in order to rule out renovascular disease such as renal artery stenosis, renal arteriovenous fistula, or renal aneurysm as a cause for the uncontrolled hypertension.

• To evaluate a patient with signs and symptoms of portal hypertension. These may include abdominal discomfort and distention, abdominal collaterals (caput medusae), abdominal bruit, ascites, encephalopathy, esophageal varices, splenomegaly, etc.

• To evaluate patients suspected of an embolism, thrombosis, hemorrhage or infarction of the portal vein, renal vein and/or renal artery. These patients may present with many different symptoms such as abdominal discomfort, hematuria, cardiac failure, diastolic hypertension, jaundice, fatigue, weakness, malaise, etc.

• To evaluate patients with pain or swelling of scrotal contents which may be as a result of suspected obstruction in arterial inflow or venous outflow to the testicles or related structures. The use of duplex scanning of scrotal contents should only be performed after conventional diagnostic test, such as ultrasound, have proven to be “non

-definitive”;

• To evaluate patients for complications of transplanted organ: kidney, liver or pancreas.

Aorta, inferior vena cava, iliac vasculature, or bypass grafts ( procedure codes 93978 and 93979):

Medicare may provide coverage for duplex scanning of aorta, inferior vena cava, iliac vasculature, or bypass grafts when performed for the following indications:

• To confirm a suspicion of an abdominal or iliac aneurysm raised by a physical examination or noted as an incidental finding on another radiological examination. The physical examination usually reveals a palpable, pulsatile and nontender abdominal mass.

• To monitor the progression of an abdominal aortic aneurysm. It is usually expected that monitoring occurs approximately every six (6) months.

• To evaluate patients presenting with signs and symptoms of a thoracic aneurysm. The symptoms usually associated with a thoracic aneurysm are substernal chest pain, back or neck pain described as deep and aching or throbbing as well as symptoms due to pressure on the trachea (dyspnea, stridor, a brassy cough), the esophagus (dysphagia), the laryngeal nerve (hoarseness), or superior vena cava (edema in neck and arms, distended neck veins).

• To evaluate patients presenting with signs and symptoms of an abdominal aneurysm. The symptoms usually associated with an abdominal aneurysm are constant pain located in the midabdomen, lumbar region or pelvis which can be severe and may be described as having a boring quality. A leaking aneurysm is characterized by lower back pain, whereas, acute pain and hypotension usually occur with rupture.

• To evaluate a patient presenting with signs and symptoms suggestive of an aortic dissection. A patient with an aortic dissection has symptoms such as a sudden onset of severe, continuous tearing or crushing pain in the chest that radiates to the back and is generally unaccompanied by EKG evidence of a myocardial infarction. On physical examination, the patient is agitated, has a murmur of aortic regurgitation, asymmetric diminution of arterial pulses and systolic bruits over the areas where the aortic lumen is narrowed.

• Initial evaluation of a patient presenting with signs and symptoms such as intermittent claudication in the calf muscles, thighs and/or buttocks, rest pain, weakness in legs or feeling of tiredness in the buttocks, etc. which may suggest occlusive disease of the aorta and iliac arteries. The physical examination usually reveals decreased or absent femoral pulses, a bruit over the narrowed artery, and possibly muscle atrophy. If severe occlusive disease exists, the patient will have atrophic changes of the skin, thick nails, coolness of the skin with pallor and cyanosis.

• To evaluate patients suspected of an abdominal or thoracic arterial embolism or thrombosis. These patients usually present with severe pain in one or both lower extremities, numbness, and symmetric weakness of the legs, with absent or severely reduced pulses below the embolism site.

• To evaluate patients presenting with complaints of pain in the calf or thigh, slight swelling in the involved leg, tenderness of the iliac vein, etc. which may suggest phlebitis or thrombophlebitis of the iliac vein or inferior vena cava.

• To evaluate a patient who has sustained trauma to the chest wall and/or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

• To assess the continued patency of both native venous and prosthetic arterial grafts following surgical intervention. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

• To monitor the sites of various percutaneous interventions, including, but not limited to angioplasty, thrombolysis/thrombectomy, atherectomy, or stent placement. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

Note: Duplex testing should be reserved for specific indications for which the precise anatomic information obtained by this technique is likely to be useful. Therefore, it would be rare to see duplex scanning being performed for conditions in which another diagnostic test is recommended (e.g., an aortic dissection is better diagnosed with a chest x-ray, transesophageal echocardiogram or aortography).

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

014x Hospital - Laboratory Services Provided to Non-patients

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

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

023x Skilled Nursing - Outpatient

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

93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY

93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY

93978 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY

93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY

ICD-9 Codes that Support Medical Necessity

Arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs (procedure codes 93975 and 93976)

288.60 LEUKOCYTOSIS, UNSPECIFIED

288.8 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS

401.9 UNSPECIFIED ESSENTIAL HYPERTENSION

440.1 ATHEROSCLEROSIS OF RENAL ARTERY

442.1 ANEURYSM OF RENAL ARTERY

442.84 ANEURYSM OF OTHER VISCERAL ARTERY

452 PORTAL VEIN THROMBOSIS

453.3 EMBOLISM AND THROMBOSIS OF RENAL VEIN

456.0 - 456.21 ESOPHAGEAL VARICES WITH BLEEDING - ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITHOUT BLEEDING

456.4 SCROTAL VARICES

557.1 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE

557.2 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE

572.3 PORTAL HYPERTENSION

593.81 VASCULAR DISORDERS OF KIDNEY

593.89 OTHER SPECIFIED DISORDERS OF KIDNEY AND URETER

599.70 HEMATURIA, UNSPECIFIED

599.71 GROSS HEMATURIA

599.72 MICROSCOPIC HEMATURIA

608.20 TORSION OF TESTIS, UNSPECIFIED

608.83 VASCULAR DISORDERS OF MALE GENITAL ORGANS

780.79 OTHER MALAISE AND FATIGUE

782.4 JAUNDICE UNSPECIFIED NOT OF NEWBORN

783.21 LOSS OF WEIGHT

785.9 OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM

789.1 - 789.09 opens in new window ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER SPECIFIED SITE

789.2 HEPATOMEGALY

789.3 SPLENOMEGALY

789.30 - 789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

789.51 MALIGNANT ASCITES

789.59 OTHER ASCITES

793.6 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM

902.20 - 902.29 INJURY TO CELIAC AND MESENTERIC ARTERIES UNSPECIFIED - INJURY TO OTHER CELIAC AND MESENTERIC ARTERIES

902.31 - 902.39 INJURY TO SUPERIOR MESENTERIC VEIN AND PRIMARY SUBDIVISIONS - INJURY TO OTHER PORTAL AND SPLENIC VEINS

902.41 INJURY TO RENAL ARTERY

902.42 INJURY TO RENAL VEIN

902.87 INJURY TO MULTIPLE BLOOD VESSELS OF ABDOMEN AND PELVIS

902.9 INJURY TO UNSPECIFIED BLOOD VESSEL OF ABDOMEN AND PELVIS

V42.0 KIDNEY REPLACED BY TRANSPLANT

V42.7 LIVER REPLACED BY TRANSPLANT

V42.83 PANCREAS REPLACED BY TRANSPLANT

Aorta, inferior vena cava, iliac vasculature, or bypass grafts (procedure codes 93978 and 93979)

424.1 AORTIC VALVE DISORDERS

440.20 - 440.29 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES

441.00 - 441.03 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - DISSECTION OF AORTA THORACOABDOMINAL

441.2 THORACIC ANEURYSM WITHOUT RUPTURE

441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE

442.2 ANEURYSM OF ILIAC ARTERY

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

444.01 - 444.09 SADDLE EMBOLUS OF ABDOMINAL AORTA - OTHER ARTERIAL EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA

444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

451.81 PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN

453.2 OTHER VENOUS EMBOLISM AND THROMBOSIS OF INFERIOR VENA CAVA

458.9 HYPOTENSION UNSPECIFIED

723.1 CERVICALGIA

724.1 PAIN IN THORACIC SPINE

724.2 LUMBAGO

729.5 PAIN IN LIMB

782.0 DISTURBANCE OF SKIN SENSATION

782.3 EDEMA

782.5 CYANOSIS

782.61 PALLOR

782.8 CHANGES IN SKIN TEXTURE

784.42 DYSPHONIA

784.43 HYPERNASALITY

784.44 HYPONASALITY

784.49 OTHER VOICE AND RESONANCE DISORDERS

784.51 DYSARTHRIA

784.59 OTHER SPEECH DISTURBANCE

785.9 OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM

786.05 SHORTNESS OF BREATH

786.1 STRIDOR

786.2 COUGH

786.50 UNSPECIFIED CHEST PAIN

789.00 - 789.09 ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER SPECIFIED SITE

789.30 - 789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE

793.6 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM

902.0 INJURY TO ABDOMINAL AORTA

902.10 INJURY TO INFERIOR VENA CAVA UNSPECIFIED

902.53 INJURY TO ILIAC ARTERY

902.54 INJURY TO ILIAC VEIN

V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY

V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V67.59 OTHER FOLLOW-UP EXAMINATION

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 ordering physician must clearly indicate the medical necessity of the services being billed. The results of the study must also be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or test results.

If the provider of the duplex scan study(ies) is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies.

Appendices

Utilization Guidelines N/a

Sources of Information and Basis for Decision

American Medical Association. (2001). Principles of CPT® Coding (2nd ed).

Coding and Payment Guide for Radiology Services. (2003). An essential coding, billing, and reimbursement resource for the Radiologist (11th ed.). Ingenix St Anthony Publishing/Medicode.

Fauci, A. S., Braunwald, E., Isselbacher, K. J., Wilson, J. D., Martin, J. B., Kasper, D. L., Hauser, S. L., & Longo,

D. L. (Eds.). Harrison’s principles of internal medicine (14th ed.). New York: McGraw-Hill.

Hockerberger, R., Marx, J., & Walls, R. (Ed). (2002). Rosen’s emergency medicine: concepts and clinical practice(5th ed.). St. Louis: Mosby, Inc. Used to provide appropriate indication for procedure.

Johansson, M., Jenson, G., Aurellm, Friberg, P., Herlitz, H., Klingenstierna, H., et al. Evaluation of duplex ultrasound and captopril renography for detection of renovascular hypertension. Kindy Int 2000; 58(2): 774-82.

Tabers cyclopedic medical dictionary (17th ed.). (1989). Philadelphia: F. A. Davis Company.

Tierney, L. M., McPhee, S. J., & Papadakis, M. A. (Eds.). (1998). Current medical diagnosis and treatment (37th ed.). Stamford: Appleton & Lange.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from the Florida Vascular Society.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 3

Revision History Explanation Revision Number: 3 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 444.0 and added diagnosis codes 444.01-444.09 to the Aorta, inferior vena cava, iliac vasculature, or bypass grafts (procedure codes 93978 and 93979) section of the LCD. The effective date of this revision is based on date of service.

Revision Number:2

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR A2010-050

September 2010 Bulletin

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted diagnosis code range 784.51-784.59 and replaced with individual diagnosis codes 784.51 and 784.59 for CPT codes 93978 and 93979. (New diagnosis code 784.52 was not added to LCD in that code range.) The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Deleted diagnosis code 784.5 for procedure codes 93978 and 93979. Added new diagnosis codes 784.42, 784.43, 784.44, 784.51 and 784.59 for procedure codes 93978 and 93979. Revised descriptor for diagnosis codes 453.2 and 784.49 for procedure codes 93978 and 93979. Revised descriptor for diagnosis code 793.6 for all procedure codes. The effective date of this revision is based on date of service.

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 A2009-034FL

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 (L28830) replaces LCD L1087 as the policy in notice. This document (L28830) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

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 14 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 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

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change