Billing and Coding: Non-Invasive Vascular Studies

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Non-Invasive Vascular Studies.

National Coverage Provisions:

42 CFR Section 410.33, Independent Diagnostic Testing Facilities: 
The supervising physician must evidence proficiency in the performance and interpretation of each type of diagnostic procedure performed by the IDTF. The proficiency may be documented by certification in specific medical specialties or subspecialties or by criteria established by the carrier for the service area in which the IDTF is located. See 42 CFR Section 410-33 (2) (b).

Nonphysician personnel. Any nonphysician personnel used by the IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department. In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. See 42 CFR Section 410-33 (2)(c).

Coding Guidelines:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

The HCPCS level II codes 93985 or 93986 should be used for the initial autogenous access vessel mapping. The CPT codes 93970 and 93971 may be used for subsequent access mapping.

If the service is done for monitoring purposes, it is not covered under Part B. No separate payment for non-invasive vascular studies for monitoring the access site of an ESRD patient, whether coded as the access site or peripheral site, is permitted to any entity.

The technical component of HCPCS codes 93985 or 93986 and CPT code 93990 (modifier TC) performed in End-Stage Renal Disease (ESRD) facilities or for ESRD patients is included in the composite payment rate. This rate is a comprehensive payment that includes all services, equipment, supplies and certain laboratory tests and drugs that are necessary for dialysis treatment.

The professional component for the procedure (modifier 26) is included in the monthly capitation payment (MCP) if billed by the MCP physician. Physicians other than the MCP provider (or a member of his/her group of the same specialty) may bill separately for interpretations of tests.

Services performed on ESRD patients by entities outside the ESRD facility must bill the ESRD facility for payment of monitoring procedures.

Definitions:

Duplex scan: An ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectrum analysis and/or color flow velocity mapping or imaging.

Physiologic studies: Functional measurement procedures that include Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurement, or plethysmography.

Plethysmography: 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. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative and postoperative evaluation of peripheral artery disease in the internal medicine or vascular surgery practice. It is also a useful tool for the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patient’s candidacy for foot surgery. (CMS Publication 100-03, Medicare National Coverage Decisions Manual, Chapter 1, Section 20.14)

Transcranial Doppler: Pulsed Doppler ultrasound is used to interrogate the intracranial vasculature of the Circle of Willis. Its value has been established in detecting severe stenosis in the major intracranial arteries, assessing patterns and extent of collateral circulation in patients with known regions of severe stenosis or occlusion and evaluating and following patients with vasoconstriction particularly after subarachnoid hemorrhage.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

It is the responsibility of the physician/provider to ensure the medical necessity of procedures and to maintain records in the event that records are requested for a post-payment audit.

42 CFR §410.32 indicates that diagnostic tests, to be covered, must be ordered by the practitioner who treats the patient. The treating physician is the practitioner responsible for the treatment of the patient. He/she orders the test to use the results in the management of the beneficiary’s specific medical problem(s). Consulting physicians may also order tests.

A referral for one non-invasive study is not a blanket referral for all studies. A referral must be on record for each non-invasive study performed.

Documentation must be provided supporting the need for more than one imaging study [Doppler flow (93990) or vessel mapping (93985, 93986) and arteriogram (75790/75820)].

Providers of interpretations and the technical portion of the examination must be capable of demonstrating documented training and experience and maintain documentation for post-payment audit.

Utilization Guidelines:

Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patient’s medical record. Guidelines for follow-up cerebrovascular arterial studies include:

• Stenosis of 20-49% (diameter reduction), an annual study;
• Stenosis of 50-79%, every six months;
• Stenosis of 80-99%, every 6 months if surgery not performed; and/or
• After carotid endarterectomy, repeat ipsilateral/unilateral examinations are allowable at six weeks, six months, and one year. During the first year, follow-up studies should be on the ipsilateral side unless signs and symptoms or previously identified disease in the contralateral carotid artery provide indications for a bilateral procedure.

If patients become symptomatic of carotid disease repeat duplex scans are allowed without regard to the above schedule.

Pre-surgical conduit mapping of the radial artery(ies) may be accompanied by vein-mapping studies when either study demonstrates that insufficient conduits are available for multiple bypass procedures.

In the immediate post-operative period, patients may be studied if re-established pulses are lost, become equivocal, or if the patient develops related signs and/or symptoms of ischemia with impending repeat intervention.

With regard to autogenous vein and synthetic lower extremity bypass surgeries, a study may be performed at three-month intervals during the first year, at six-month intervals during the second year, and annually thereafter. The frequency of medically necessary follow-up studies post-angioplasty is dictated by the vascular distribution treated.