L29293-LCD

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Local Coverage Determination (LCD) for Transcranial Doppler Studies (L29293)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29293

LCD Title

Transcranial Doppler Studies

Contractor's Determination Number 93886

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 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2009

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. 100-3, Medicare National Coverage Determinations, Chapter 1, Part 1, Sections 20.14

and 20.17

CMS Manual System, Pub. 100-3, Medicare National Coverage Determinations, Chapter 1, Part 4, Section 220.5 CMS Manual System, Pub. 100-8, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

Transcranial doppler uses low-frequency doppler transducers applied across the thin portions of the temporal bone (the temporal acoustic windows) to obtain flow velocity information from the basal intracerebral arteries. The transtemporal acoustic window provides access to hemodynamic data from the middle, anterior, and posterior cerebral arteries. A suboccipital approach, with insonation through the foramen magnum, provides access to the intracranial vertebral and basilar arteries, while a transorbital approach can be used to insonate the ophthalmic artery and the carotid siphon via the optic foramen. This data allows evaluation of the direction, depth, speed, and characteristics of flow in these vessels.

Medicare considers transcranial doppler evaluation of the intracranial cerebrovascular system to be considered medically necessary in any of the following circumstances (see the “ICD-9 Codes That Support Medical Necessity” section of this policy):

• The patient has suspected severe intracranial arterial stenosis based on finite clinical evidence of focal ischemia, and knowledge of this stenosis is necessary in order to properly care for the patient.

• The patient has areas of known severe stenosis or occlusion of arteries supplying the brain and assessment of the pattern and extent of collateral circulation is necessary in order to properly care for the patient.

• The patient has suffered a subarachnoid hemorrhage and transcranial doppler studies are necessary to assess vasoconstriction of cerebral vessels.

• The patient has suspected or confirmed arteriovenous malformation, and an assessment of the arterial supply and flow pattern is necessary.

• The patient has suspected brain death.

Headaches or dizziness are not indications for transcranial doppler studies of the intracranial vessels unless associated with other localizing signs and symptoms such as nystagmus, limb ataxia, etc.

Transcranial doppler studies performed to monitor cerebral vascular resistance and the effects of vasodilators and other drugs in the treatment of stroke and other brain damage is considered investigational, and therefore not covered by Medicare.

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 part of the physical examination of the vascular system and is not separately reported (CPT 2004, page 355). 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.

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

93886 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; COMPLETE STUDY

93888 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; LIMITED STUDY

93890 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; VASOREACTIVITY STUDY

93892 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITHOUT INTRAVENOUS MICROBUBBLE INJECTION

93893 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITH INTRAVENOUS MICROBUBBLE INJECTION

ICD-9 Codes that Support Medical Necessity

348.81 - 348.89 opens innew window TEMPORAL SCLEROSIS - OTHER CONDITIONS OF BRAIN

430 SUBARACHNOID HEMORRHAGE

433.1 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION

433.2 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION

433.10 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION

433.11 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION

433.20 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL INFARCTION

433.21 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION

433.30 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION

433.31 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION

434.1 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION

434.2 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION

434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION

434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION

434.90 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION

434.91 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION

435.1 BASILAR ARTERY SYNDROME

435.2 VERTEBRAL ARTERY SYNDROME

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

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 transcranial doppler studies covered by the Medicare program. Also, the results of transcranial doppler studies covered by the Medicare program must 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 transcranial doppler 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 physican/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her order for the test.

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

Society of Vascular Ultrasound-Professional performance guidelines. (2003). Transcranial Doppler (Non-Imaging). Retrieved September 13, 2005, from http://www.svunet.org/about/positions.

Sloan, M.A., Alexandrov, A.V., Tegeler, C.H., Spencer, M.P., Caplan, L.R., Feldman, E., et al. (2004). Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of The American Academy of Neurology. Retrieved September 13, 2005, from http://www.neurology.org/cgi/content/full/62/9/1468.

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 10/01/2009

Revision History Number 1

Revision History Explanation 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 B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Deleted diagnosis 348.8 and replaced with diagnosis code range 348.81-349.89. 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:02/02/2009

LCR B2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29293) replaces LCD L6641 as the policy in notice. This document (L29293) is effective on 02/02/2009.

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

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

93890 descriptor was changed in Group 1 93892 descriptor was changed in Group 1 93893 descriptor was changed in Group 1

Reason for Change ICD9 Addition/Deletion