This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L33695 Non-invasive Extracranial Arterial Studies 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.
1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. 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.
3. 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.
4. A hard copy, or a soft copy convertible to a hard copy provides a permanent record of the study performed and must be of a quality that meets accepted radiologic/ultrasonographic standards.
5. If the provider of the service is other than the ordering/referring physician/nonphysician practitioner, that provider 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 physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her order for the test. Billing providers are encouraged to obtain additional information from referring providers and/or patients or medical records. Referring physicians are required to provide appropriate diagnostic information to the performing provider.
6. 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 L33695, Non-invasive Extracranial Arterial Studies may be monitored and addressed through post payment data analysis and subsequent medical review audits.