L28936-LCD

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Local Coverage Determination (LCD) for Non-Invasive Evaluation of Extremity Veins (L28936)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28936

LCD Title Non-Invasive Evaluation of Extremity Veins

Contractor's Determination Number A93965

Primary Geographic Jurisdiction opens in new window

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 11/15/2011

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 other wise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 80

CMS Manual System Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Section(s) 20.14,

20.29 , 220.5

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1 42 CFR 410.32

Indications and Limitations of Coverage and/or Medical Necessity

Non-invasive vascular diagnostic studies utilize ultrasonic Doppler and physiologic principles to assess irregularities in blood flow in the venous system. 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.

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 2010. 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. 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.

Definitions

A duplex scan is an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging.

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

Indications

First Coast Service Options, Inc. (FCSO) Medicare will consider non-invasive evaluation of extremity veins to be medically necessary under any of the following circumstances:

• The patient has deep venous thrombophlebitis or has clinical findings (otherwise unexplained limb pain, swelling) which suggest the possibility of acute deep venous thrombophlebitis.

• The patient presents with signs and symptoms of pulmonary embolism (PE) indicated by dyspnea, chest pain, and/or hemopytsis.

• The patient has acute pulmonary embolism.

• Evaluation of patient with symptomatic varicose veins such as stasis ulcer of the lower leg, significant pain and significant edema that interferes with activities of daily living that have not resolved following three months of conservative therapy, and symptoms are suspected to be secondary to venous insufficiency, and testing is performed to confirm this diagnosis by documenting venous valvular incompetence prior to an invasive therapeutic intervention, which meets criteria for medical necessity as outlined in FCSO Medicare LCD Treatment of varicose veins of the lower extremity.

• The patient has chronic venous insufficiency, post phlebitic syndrome, or lymphedema.

• The patient has sustained trauma and injury of the venous system is suspected, making evaluation of the venous system of extremities necessary.

• Venous mapping for the selection of a vein suitable for creating a dialysis fistula or prior to revascularization.

• Evaluation of possible venous obstruction or thrombosis in hospitalized patients who have recently undergone procedures, which predispose them to thrombosis and who would not have been therapeutically anti-coagulated otherwise (eg, hip replacements, knee replacements).

Venous mapping is not always indicated as a routine pre-operative study. However, this procedure may be useful prior to surgical revascularization or creation of a dialysis fistula as part of the patient’s clinical evaluation in determination of an adequate venous conduit.

Limitations

Performance of both physiological testing (93965) and duplex scanning (93970 or 93971) of extremity veins during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected (American College of Radiology). Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request. Note: Reimbursement of physiologic testing will not be allowed after a duplex scanning 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. Consequently, documentation must clearly support the medical necessity of both procedures if performed during the same encounter, and be available to Medicare upon request.

Non-invasive vascular studies are considered medically necessary only if the outcome will potentially impact the clinical course of the patient. 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. 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.

Performance of both non-invasive extracranial arterial studies (CPT codes 93880 or 93881) and non-invasive evaluation of extremity veins (CPT codes 93965, 93970 or 93971) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected (American College of Radiology, 2010). Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

When an uninterpretable study results in performing another type of study, only the successful study should be billed. For example, when an uninterpretable non-invasive physiologic study (93965) is performed which results in performing a duplex scan (93970 or 93971), only the duplex scan should be billed.

It is not considered medically reasonable and necessary to study asymptomatic varicose veins.

Methods Not Acceptable for Reimbursement

The following methods are not covered per CMS Manual System, Pub 100-03, Medicare National Coverage Determinations, Chapter 1, Section 20.14 as these methods have not yet reached a level of development such as to allow their routine use in the evaluation of suspected peripheral vascular disease.

• Inductance Plethysmography

• Capacitance Plethysmography

• Mechanical Oscillometry

• Photoelectric Plethysmography]

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

All non-invasive vascular diagnostic studies must be: (1) performed by a qualified physician, or (2) 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, and/or (3) performed in a laboratory accredited in vascular technology.

The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 13.5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf) outlines that “reasonable and necessary” services

are “ordered and/or furnished by qualified personnel.” Services will be considered medically reasonable and

necessary only if performed by appropriately trained providers.

A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare.

B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

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

• Registered Vascular Technologist (RVT) credential

• Registered Vascular Specialist (RVS) credential

• Registered Phlebology Sonographer (RPhS)

• Registered Technologist in Vascular Sonography (R.T. [VS])

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

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

• The Cardiovascular Credentialing International (CCI) which provides RVS and RPhS credentials

• The American Registry of Radiologic Technologists (ARRT)

Appropriate nationally recognized laboratory accreditation bodies include:

• Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL)

• American College of Radiology (ACR)

However, if the facility has a documented process for grand-fathering experienced technicians who have performed the services referenced in this LCD (a process addressing years of service and experience with number of supervised cases), this documentation should be available to Medicare upon request; otherwise the provider must have documentation available to Medicare upon request which indicates that the technician meets the credentialing requirements as stated above or is in the process of obtaining this credentialing.

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. 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.

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

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

NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, 93965 DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS,

PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY)

93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY

93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY

ICD-9 Codes that Support Medical Necessity

415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION

415.12 SEPTIC PULMONARY EMBOLISM

415.13 SADDLE EMBOLUS OF PULMONARY ARTERY

415.19 OTHER PULMONARY EMBOLISM AND INFARCTION

427.31 ATRIAL FIBRILLATION

451.0 PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES

451.11 PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL)

451.19 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER

451.2 PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED

451.81 PHLEBITIS AND THROMBOPHLEBITIS OF ILIAC VEIN

451.82 PHLEBITIS AND THROMBOPHLEBOTIS OF SUPERFICIAL VEINS OF UPPER EXTREMITIES

451.83 PHLEBITIS AND THROMBOPHLEBITIS OF DEEP VEINS OF UPPER EXTREMITIES

451.89 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER SITES

453.40 - 453.42 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY - ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY

453.50 - 453.52 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY - CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF DISTAL LOWER EXTREMITY

453.6 VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITY

453.71 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY

453.72 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY

453.73 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED

453.74 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS

453.75 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS

453.76 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS

453.81 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUPERFICIAL VEINS OF UPPER EXTREMITY

453.82 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VEINS OF UPPER EXTREMITY

453.83 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY, UNSPECIFIED

453.84 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF AXILLARY VEINS

453.85 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF SUBCLAVIAN VEINS

453.86 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF INTERNAL JUGULAR VEINS

454.1 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER

454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH INFLAMMATION

454.3 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION

454.8 VARICOSE VEINS OF LOWER EXTREMITIES WITH OTHER COMPLICATIONS

457.1 OTHER LYMPHEDEMA

459.10 - 459.19 POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION

459.81 VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED

518.81 ACUTE RESPIRATORY FAILURE

729.5 PAIN IN LIMB

729.81 SWELLING OF LIMB

757.0 HEREDITARY EDEMA OF LEGS

782.3 EDEMA

782.5 CYANOSIS

785.0 TACHYCARDIA UNSPECIFIED

786.1 - 786.09 RESPIRATORY ABNORMALITY UNSPECIFIED - RESPIRATORY ABNORMALITY OTHER

786.2 STRIDOR

786.3 COUGH

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

786.4 ABNORMAL SPUTUM

786.50 UNSPECIFIED CHEST PAIN

786.51 PRECORDIAL PAIN

786.52 PAINFUL RESPIRATION

786.59 OTHER CHEST PAIN

794.2 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM

799.02 HYPOXEMIA

901.2 INJURY TO SUPERIOR VENA CAVA

901.3 INJURY TO INNOMINATE AND SUBCLAVIAN VEINS

902.10 INJURY TO INFERIOR VENA CAVA UNSPECIFIED

902.50 INJURY TO ILIAC VESSEL(S) UNSPECIFIED

902.87 INJURY TO MULTIPLE BLOOD VESSELS OF ABDOMEN AND PELVIS

903.00 INJURY TO AXILLARY VESSEL(S) UNSPECIFIED

903.02 INJURY TO AXILLARY VEIN

903.1 INJURY TO BRACHIAL BLOOD VESSELS

903.2 INJURY TO RADIAL BLOOD VESSELS

903.3 INJURY TO ULNAR BLOOD VESSELS

903.5 INJURY TO DIGITAL BLOOD VESSELS

903.8 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF UPPER EXTREMITY

903.9 INJURY TO UNSPECIFIED BLOOD VESSEL OF UPPER EXTREMITY

904.2 INJURY TO FEMORAL VEINS

904.3 INJURY TO SAPHENOUS VEINS

904.40 INJURY TO POPLITEAL VESSEL(S) UNSPECIFIED

904.42 INJURY TO POPLITEAL VEIN

904.50 INJURY TO TIBIAL VESSEL(S) UNSPECIFIED

904.52 INJURY TO ANTERIOR TIBIAL VEIN

904.54 INJURY TO POSTERIOR TIBIAL VEIN

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

996.62 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT

V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V72.83 OTHER SPECIFIED PRE-OPERATIVE 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/referring physician/nonphysician practitioner must clearly indicate the medical necessity of non-invasive venous studies covered by the Medicare program and be available to Medicare upon request. Also, the results of non-invasive venous studies covered by the Medicare program must be included in the patient's medical record.

If the provider of non-invasive venous 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 FCSO Medicare upon request. Non-invasive vascular studies are medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. 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. Referring physicians are required to provide appropriate diagnostic information to the performing provider.

The medical necessity for performing both physiologic studies and duplex scanning during the same encounter 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. Tests not ordered by the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

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 Practice Guidelines. (2006). ACR Practice guidelines for the performance of peripheral venous ultrasound examination. Retrieved from http://www.acr.org.

Other Contractor's Policies

Pellerito, J.S. (2001). Current approach to peripheral arterial sonography. Radiologic Clinics of North America. (39), 3. 553-567. This source was used to provide indications.

Society for Vascular Ultrasound–Professional performance guidelines. (2004). Lower extremity venous insufficiency evaluation. (2003). Upper extremity vein mapping. 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.

The complete ICAVL standards for accreditation in noninvasive vascular testing. Parts I through VII. (2010). ICAVL Standards. Retrieved from http://icavl.org.

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 advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/09/2010

Revision History Number 7

Revision History Explanation Revision Number:7 Start Date of Comment Period:N/A

Start Date of Notice Period:12/01/2011 Revised Effective Date: 11/15/2011

LCR A2011-090

November 2011 Connection

Explanation of Revision: The ‘Training Requirements’ section of the LCD has been revised to add ‘Registered technologist in vascular sonography (R.T. [VS])’as an additional example of certification in vascular technology

for non-physician personnel and to indicate that this credential is provided by the American Registry of Radiologic Technologists (ARRT). The effective date of this revision is based on date of service.

Revision Number: 6

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. Added diagnosis code 415.13. The effective date of this revision is based on date of service.

Revision Number:5

Start Date of Comment Period:N/A Start Date of Notice Period:07/01/2011 Revised Effective Date:06/14/2011

LCR A2011-060

June 2011 Connection

Explanation of Revision: Based on an outside request to clarify our current training statement outlined in this LCD, language under the “Limitations” section of the LCD has been deleted and replaced with a revised statement regarding the qualification and training. Revisions will be effective based on process date.

Revision Number:4

Start Date of Comment Period:09/30/2010 Start Date of Notice Period:12/09/2010 Revised Effective Date:01/23/2011

LCR A2010-066

December 2010 Bulletin

Explanation of Revision: The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD has been revised under the ‘Indications’ section in regard to varicose veins. A ‘Limitations’ section has also been added. The ‘Training Requirements’ section has also been revised to add an additional example of certification in vascular technology for non-physician personnel: Registered Phlebology Sonographer (RPhS)’ that is provided by Cardiovascular Credentialing International. The ‘ICD-9 Codes that Support Medical Necessity’ section has also been revised to add ICD-9-CM codes 453.75, 453.76, 453.85 and 453.86.

The ‘Documentation Requirements’ section has been revised to add language regarding services billed by providers other than the ordering provider, documentation requirements when performing both physiologic studies and duplex scanning during the same encounter, when performing arterial and venous studies during the same encounter, and when performing non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins during the same encounter. The ‘Sources of Information and Basis for Decision’ section of the LCD has also been updated. The effective date of this revision is based on date of service.

Revision Number:3

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 ICD-9-CM code 786.3 and replaced with new ICD-9-CM codes 786.30 and 786.39. 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:08/01/2010 Revised Effective Date:07/08/2010

LCR A2010-031

July 2010 Bulletin

Explanation of Revision: The ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of LCD revised and updated. Revisions include descriptors for physiologic studies and plethysmography procedures. Language also added in the ‘Training Requirements’ section of the LCD regarding the definition of a qualified physician. 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. Added new diagnosis codes 453.50-453.52, 453.6, 453.71, 453.72, 453.73, 453.74, 453.81, 453.82, 453.83, and 453.84. Deleted diagnosis code 453.8. Revised descriptor for diagnosis codes 453.40-453.42. 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 (L28936) replaces LCD L937 as the policy in notice. This document (L28936) 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 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

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

Reason for Change