Description
This review will determine if a duplex scan of the extracranial arteries reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied.
Affected Code(s)
93880, 93882
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. 42 CFR §410.32(a)- Ordering Diagnostic Tests
9. 42 CFR §410.32(b)- Diagnostic x-ray and other diagnostic tests
10. 42 CFR §410.33- Independent Diagnostic Testing Facility
11. National Coverage Determinations Manual, Chapter 1, Part 1, §20.17- Noninvasive Tests of Carotid Function
12. National Coverage Determinations Manual, Chapter 1, Part 4, §220.5- Ultrasound Diagnostic Procedures
13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1 –3.6 .6
14. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures
15. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80- Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
16. CGS LCD L34045: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 10/20/2021
17. First Coast LCD L33695: Non-Invasive Extracranial Arterial Studies; Effective 10/01/2015; Revised 01/08/2019
18. NGS LCD L33627: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 10/01/2019
19. Noridian LCD L34221: Noninvasive Cerebrovascular Studies; Effective 10/01/2015; Revised 10/01/2019; Retired 5/11/2020
20. Novitas LCD L35397: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 10/17/2019
21. WPS LCD L35753: Non-Invasive Cerebrovascular Studies; Effective 10/01/2015; Revised 10/1/2021
22. CGS LCA A56697: Billing and Coding: Non-Invasive Vascular Studies; Effective 07/11/2019; Revision Effective: 10/21/2021
23. First Coast LCA A57670: Billing and Coding: Non-Invasive Extracranial Arterial Studies; Effective 10/03/2018
24. NGS LCA A56758: Billing and Coding: Non-Invasive Vascular Studies; Effective 08/01/2019; Revised 01/01/2020, 03/01/2020, 10/01/2020; Revised Effective Date 02/25/2021
25. Noridian LCA A57199: Billing and Coding: Noninvasive Cerebrovascular Studies; Effective 10/01/2019; Retired 5/11/2020
26. Novitas LCA A52992: Billing and Coding: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 8/02/2019
27. WPS LCA A57592: Billing and Coding: Non-Invasive Cerebrovascular Studies; Effective 11/01/2019; Revisions 10/01/2021
28. CPT Manual