LCD/NCD Portal

L28936 NON-INVASIVE EVALUATION OF EXTREMITY VEINS

 

 

11/15/2011

 

 

Indications and Limitations of Coverage and/or Medical Necessity

 

• 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.

 

 

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

o Dyspnea.

o Chest pain.

o 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:

o Three months of conservative therapy.

o Symptoms are suspected to be secondary to venous insufficiency.

o 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

o Chronic venous insufficiency.

o Post phlebitic syndrome.

o 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 (e.g., hip replacements, knee replacements).

• Venous mapping is not always indicated as a routine pre-operative study.

o 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).

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 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.

o 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.

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.

• 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).

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.

• When an uninterpretable study results in performing another type of study, only the successful study should be billed.

o 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.

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.

• 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.”

o 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:

o Physician is properly enrolled in Medicare.

o 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:

o Registered Vascular Technologist (RVT) credential.

o Registered Vascular Specialist (RVS) credential.

o Registered Phlebology Sonographer (RPhS).

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

• 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 and RPhS credentials.

o The American Registry of Radiologic Technologists (ARRT).

• 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.

 

 

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

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

 

93965 NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, 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 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY

453.41 ACUTE VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY

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

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

453.51 CHRONIC VENOUS EMBOLISM AND THROMBOSIS OF DEEP VESSELS OF PROXIMAL LOWER EXTREMITY

453.52 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

454.0 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER

454.1 VARICOSE VEINS OF LOWER EXTREMITIES WITH INFLAMMATION

454.2 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 POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS

459.11 POSTPHLEBETIC SYNDROME WITH ULCER

459.12 POSTPHLEBETIC SYNDROME WITH INFLAMMATION

459.13 POSTPHLEBETIC SYNDROME WITH ULCER AND INFLAMMATION

459.19 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

786.00 RESPIRATORY ABNORMALITY UNSPECIFIED

786.01 HYPERVENTILATION

786.02 ORTHOPNEA

786.03 APNEA

786.04 CHEYNE-STOKES RESPIRATION

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.07 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

786.1 STRIDOR

786.2 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

 

 

Documentation 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.

o 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.

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.

• The medical necessity for performing both physiologic studies and duplex scanning during the same encounter must be clearly documented in the medical record.

• 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 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).

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.

• 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 a year excluding

o Inpatient hospital (21).

o Emergency room (23) places of service.

Treatment Logic

• 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.

o Physiologic studies are functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmography.

o 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.

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.

• 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.

• 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.

 

 

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.

 

FCSO LCD 29234, Non-Invasive Evaluation of Extremity Veins, 11/15/2011. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Other Contractor’s Policies

 

Pellegrino, 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.

 

 

AMA CPT Copyright Statement

 

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD NON-INVASIVE EVALUATION OF EXTREMITY VEINS