Local Coverage Article:
Billing and Coding: Duplex Scan Of Lower Extremity Arteries (A57064)
Select the Print Complete Record, Add to Basket or Email Record Buttons to print the record, to add it to your basket or to email the record.
To print an entire document, use the Need a PDF Button or the Print Complete Record Button.
Note: Documents with coding fields will include all codes in each group.
To print only the current visible page contents, use the Print Button in the page header.
General Article Information Table
Billing and Coding: Duplex Scan Of Lower Extremity Arteries
Billing and Coding
AMA CPT / ADA CDT / AHA NUBC Copyright Statement
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
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.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
Copyright © 2013 - 2020, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with
permission. No portion of the American Hospital Association (AHA) copyrighted materials contained
within this publication may be copied without the express written consent of the AHA. AHA copyrighted
materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any
software, product, service, solution or derivative work without the written consent of the AHA. If an
entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or
utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal
purposes, resale and/or to be used in any product or publication; creating any modified or derivative
work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04
Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an
express license from the American Hospital Association. To license the electronic data file of UB-04 Data
Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at firstname.lastname@example.org.
Original Effective Date
Revision Effective Date
CMS National Coverage Policy
This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33667 Duplex Scan of Lower Extremity Arteries provides billing and coding guidance for frequency limitations as well as diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must clearly indicate the medical necessity of duplex scan of lower extremity arteries i.e., signs and symptoms, relevant history (including known diagnoses, and/or prior imaging). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Also, the results of the duplex scan of lower extremity arterial studies must be included in the patient's medical record. A hard copy or soft copy convertible to a hard copy provides a permanent record of the study performed and must be of a quality that meets accepted medical standards.
- If the provider of duplex scan of lower extremity arterial 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. When ordering duplex scan of lower extremity arterial studies, the ordering/referring physician/nonphysician practitioner must state the reason for the duplex scan of lower extremity arteries in his/her order for the test.
- The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available upon request. Billing providers 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 repeat extremity arterial studies must be clearly documented in the medical record.
- An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L33667 Duplex Scan of Lower Extremity Arteries may be monitored and addressed through post payment data analysis and subsequent medical review audits.
Group 1 Paragraph: N/A
Group 1 Codes:
CPT/HCPCS Codes Information Table
||DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY
||DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY
Group 1 Paragraph: N/A
Group 1 Codes: N/A
ICD-10 Codes that Support Medical Necessity
ICD-10 Codes that DO NOT Support Medical Necessity
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
article does not apply to that Bill Type. Complete absence of all Bill Types indicates
that coverage is not influenced by Bill Type and the article should be assumed to
apply equally to all claims.
Bill Type Codes Information Table
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 article, 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 article should be assumed to apply equally to all Revenue Codes.
The Revenue Codes Information Table
Group 1 Paragraph: N/A
Group 1 Codes: N/A
This Billing and Coding Article was created to support change request 10901, which indicates all CPT and ICD-10-CM codes shall be removed from LCDs and placed in billing & coding articles that are to be published to the MCD and related to the LCD.
Related Local Coverage Document(s)
Related National Coverage Document(s)
Statutory Requirements URL(s)
Rules and Regulations URL(s)
CMS Manual Explanations URL(s)
Updated on 10/02/2019 with effective dates 10/03/2018 - N/A