Noninvasive Extracranial Arterial Studies

Transcription

1 Noninvasive Extracranial Arterial Studies Noridian Healthcare Solutions, LLC Please Note: This is a Proposed LCD. Proposed LCDs are works in progress and not necessarily a reflection of the current policies or practices. Proposed LCDs in an approval status display on the CMS MCD for public review. Contractor Information Contractor Name Noridian Healthcare Solutions, LLC Contract Number Contract Type A and B MAC Associated Contract Numbers Proposed LCD Information (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC, (A and B MAC J - F) Noridian Healthcare Solutions, LLC 1

2 Proposed LCD ID Proposed LCD Version Proposed LCD Title DL Noninvasive Extracranial Arterial Studies CPT only copyright American Medical Association. All rights reserved. AMA CPT ADA CDT AHA NUBC Copyright Statements CDT only copyright 2016 American Dental Association. All rights reserved. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ("AHA"), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. 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 [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. CMS National Coverage Policy Jurisdiction Super MAC J - F Jurisdiction Coverage Guidance Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub , Medicare Benefit Policy Manual, Chapter 15, Section 80 CMS Manual System, Pub , Medicare National Coverage Determinations, Chapter 1, Sections 20.14, 20.17, 20.29, and CMS Manual System, Pub , Medicare Program Integrity Manual, Chapter 13, Section CFR Arizona 2

3 Non-invasive tests for cerebrovascular arterial function document the nature, location, extent and severity of disease in extracranial and intracranial vessels including the carotid and vertebral arteries. Non-invasive extracranial arterial studies involve the use of direct and occasionally indirect methods of ultrasound. The direct tests examine the anatomy and physiology of the carotid artery, while the indirect tests examine hemodynamic changes in the distal beds of the carotid artery (the orbital and cerebral circulations). It is important to note that the names of these tests are not standardized. Examples of acceptable tests include: Direct Tests: Carotid Phonoangiography Coverage Indications, Limitations and/or Medical Necessity Direct Bruit Analysis Spectral Bruit Analysis Doppler Flow Velocity Ultrasound Imaging including Real Time B-Scan and Doppler Devices Indirect Tests: 3

4 Periorbital directional Doppler ultrasonography Oculoplethysmography Ophthalmodynamometry Doppler ultrasonography is used to evaluate hemodynamic parameters, specifically the velocity of blood flow and the pattern or characteristics of flow. The doppler ultrasound involves the evaluation of the supraorbital, common carotid, external carotid, internal carotid, and the vertebral arteries in the extracranial cerebrovascular assessment. The second key component of vascular diagnostic ultrasound is the B- mode, or brightness-mode image. This real time imaging technique provides a two-dimensional gray-scale image of the soft tissues and vessels based on the acoustic properties of the tissues. Duplex ultrasonography combines the direct visualization capabilities of B- mode ultrasonography and the blood-flow velocity measurements of doppler ultrasonography. Definitions: A physiologic study implies functional measurement procedures including Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements or plethysmograhy. A complete study includes pressure measurements and an additional physiologic technique (eg, Doppler waveforms or plethysmography). Plethysmography implies volume measurement procedures including air, impedance, or strain gauge methods. A duplex scan implies an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and 4

5 Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging. Indications: Non-invasive extracranial arterial studies will be considered medically reasonable and necessary under the following circumstances: To initially evaluate a patient presenting with an asymptomatic carotid bruit identified on physical examination. However, repeatedly using this test for a patient with an asymptomatic carotid bruit with no evidence of carotid stenosis is routine monitoring. As such, it is considered screening and is noncovered. To evaluate a symptomatic patient with a carotid bruit(s). To monitor a patient with known carotid stenosis. Patients demonstrating a diameter reduction of 30-50% are normally followed on an annual basis, whereas patients with a diameter reduction of greater than 50% are normally followed every six months. It is not necessary to monitor patients with a diameter reduction of less than 30%. To initially evaluate a patient who has had a recent stroke (recent is defined as less than six months) to determine the cause of the stroke. To evaluate a patient with focal cerebral or ocular transient ischemic symptoms (including, but not limited to, localizing symptoms, weakness of one side of the face, slurred speech, weakness of limb, ocular microembolism, arterial occlusions on retinal examination (branch or central), ischemic optic neuropathy, suspected dural or carotid cavernous fistulae). Ocular transient ischemic attacks are defined as retinal or visual field deficits and not temporarily blurred vision. 5

6 To evaluate a patient with syncope that is strongly suggestive of vertebrobasilar or bilateral carotid artery disease in etiology, as suggested by medical history. To evaluate a patient with retinal arterial emboli (Hollenhorst plaques). To evaluate a patient with transient monocular blindness (amaurosis fugax). To evaluate a patient with signs/symptoms of subclavian steal syndrome. The symptoms usually associated with subclavian steal syndrome are a bruit in the supraclavicular fossa, unequal radial pulses, arm claudication following minimal exercise, and a difference of 20mmHg or more between the systolic blood pressures in the arms. To evaluate a patient with proven carotid disease on medical management in whom cerebrovascular symptoms become recurrent. To evaluate a patient presenting with an injury to the carotid artery or blunt neck trauma. To evaluate a patient with vasculitis involving the extracranial carotid arteries. To evaluate a patient with a suspected aneurysm of the carotid artery. This is suspected in patients with swelling of the neck particularly if occurring post carotid endarterectomy. 6

7 To evaluate a patient with suspected dissection. To evaluate pulsatile neck masses. To monitor patients who are post carotid endarterectomy. These patients are normally followed with duplex ultrasonography on the affected side at 6 weeks, 6 months, 1 year, and annually thereafter. To preoperatively validate the degree of carotid stenosis of a patient whose previous duplex scan revealed a greater than 70% diameter reduction. The duplex is only covered when the surgeon questions the validity of the previous study and the repeat test is being performed in lieu of a carotid arteriogram. Preoperative evaluation of patients scheduled for major cardiovascular surgical procedures when there is evidence of systemic atherosclerosis. Non-invasive vascular studies are medically necessary only if the outcome will potentially impact the clinical management of the patient. Services are deemed medically necessary when all of the following conditions are met: 1. Significant signs/symptoms of ischemia are present; 2. The information is necessary for appropriate medical and/or surgical management; and 3. The test is not redundant of other diagnostic procedures that must be performed. 7

8 Limitations: Dizziness is not a typical indication unless associated with other localizing signs or symptoms. However, episodic dizziness with symptom characteristics typical of transient ischemic attacks may indicate medical necessity, especially when other more common sources (e.g., postural hypotension, arrhythmia or transiently decreased cardiac output as demonstrated by cardiac events monitoring) have been previously excluded. When reporting syncope as an indication for this service, it is necessary to document that other, more common causes have been ruled out. When an uninterpretable study results in performing another type of study, only the successful study should be billed. Non-invasive studies are reasonable and necessary only if the outcome will potentially impact the clinical course of the patient. For example, the studies are unnecessary when the patient is (or is not) proceeding on to other diagnostic and/or therapeutic procedures regardless of the outcome of the non-invasive studies. If it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then non-invasive vascular studies are not medically necessary. Performance of both non-invasive extracranial arterial studies (CPT codes or 93882) and non-invasive evaluation of extremity veins (CPT codes or 93971) during the same is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected (American College of Radiology, 2010). Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same, and be available upon request. Methods Not Acceptable For Reimbursement: 8

9 Pulse delay oculoplethysmography Carotid phonoangiography and other forms of bruit analysis are covered services, but are included in the reimbursement for the office visit Periorbital photoplethysmography Thermography Light reflection rheography Photoelectric plethysmograph, Mechanical oscillometry Inductance plethysmography Capitance plethysmography 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 2010). 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 9

10 exam, printout, and report must be in keeping with accepted national standards. Since, the standard for the above indications is a color-duplex scan, portable equipment must be able to produce combined anatomic and spectral flow measurements. Training Requirements: The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill and experience of the technologist and the physician performing the interpretation of the study. Consequently, the technologist and the physician must maintain proof of training and experience. All non-invasive vascular diagnostic studies must be: (1) performed by a qualified physician, or (2) performed under the general supervision of a qualified physician by a technologist who has demonstrated minimum entry level competency by being credentialed in vascular technology, and/or (3) performed in a laboratory accredited in vascular technology. A qualified physician for this service is defined as follows: 1) A physician who has staff privileges to interpret vascular laboratory studies in a hospital that participates in the Medicare program for the states within Noridian's Jurisdiction (as applicable) or; 2) A physician who works in a certified vascular laboratory or; 3) A physician who has the RVT or the RPVI (Registered Physician in Vascular interpretation provided by the ARDMS) certificate or ASN: Neuroimaging Subspecialty Certification. Examples of certification in vascular technology for non-physician personnel include: Registered Vascular Technologist (RVT) credential Registered Vascular Specialist (RVS) credential Registered Technologist in Vascular Sonography (R.T. (VS)) These credentials must be provided by nationally recognized credentialing organizations such as: 10

11 The American Registry of Diagnostic Medical Sonographers (ARDMS) which provides RDMS and RVT credentials The Cardiovascular Credentialing International (CCI) which provides RVS credential The American Registry of Radiologic Technologists (ARRT) Appropriate nationally recognized laboratory accreditation bodies include: Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) American College of Radiology (ACR) However, if the facility has a documented process for grand-fathering experienced technicians who have performed the services referenced in this LCD (a process addressing years of service and experience with number of supervised cases), this documentation should be available upon request; otherwise the provider must have documentation available upon request which indicates that the technician meets the credentialing requirements as stated above or is in the process of obtaining this credentialing. General Supervision means the procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. Proposed Process Information 11

12 Synopsis of Changes Changes Not Applicable Fields Changed Documentation Requirements Medical record documentation maintained by the ordering/referring physician/nonphysician practitioner must clearly indicate the medical necessity of the services being billed. In addition, documentation that the service was performed 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. 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. 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. Associated Information The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available upon request. Non-invasive vascular studies are medically reasonable and necessary only if the outcome will potentially impact the diagnosis or clinical course of the patient. 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. Performance of both non-invasive extracranial arterial studies (CPT codes or 93882) and non-invasive evaluation of extremity veins (CPT codes or 93971) during the same is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected (American College of Radiology, 2010). Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same, and be available upon request. Per 42 CFR , all diagnostic tests must be ordered by the physician/nonphysician practitioner who is treating the patient, that is, the physician/nonphysician practitioner who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient s specific medical problem. Tests not ordered by 12

13 the physician/nonphysician practitioner who is treating the patient are not reasonable and necessary. When reporting syncope as an indication for this service, it is necessary to document that other, more common causes have been ruled out. Documentation must support the criteria for coverage as set forth in the Indications and Limitations of Coverage and/or Medical Necessity section of this LCD and should reflect how the results of this test will be used in the patient s plan of care. 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. Generally, it is not expected that these services would be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of service. 1. FCSO reference LCD number(s) L28958, L29235, L29321 Sources of Information and Basis for Decision 2. Abuhamad, A., Benacerraf, B., Woletz, P., Burke, B. (2004). The accreditation of ultrasound practices Impact on compliance with minimum performance guidelines.j Ultrasound Med, 23, American College of Radiology Practice Guidelines (2007). ACR practice guideline for the performance of an ultrasound examination of the extracranial cerebrovascular system. Retrieved from ACR.org 13

14 4. Beers, M., Berkow, R. (Eds.). (2005). Ischemic Syndromes. The Merck Manual of Diagnosis and Therapy (17 ed.), Retrieved from Merck.com 5. Brophy, D. (2005). Subclavian Steal Syndrome. Retrieved from emedicine.com 6. Caplan, L. (2004). Clinical diagnosis of patiens with cerebrovascular disease. Prim Care, 31(1), Retrieved from mdconsult.com 7. Cina, C., Clase, C., Radan, A. (2004). Aysmptomatic Carotid Bruit. ACS Surgery. Retrieved from medscape.com 8. Hill, M., Foss., Tu., Feasby, T. (2004). Factors influencing the decision to perform carotid endarterectomy. Neurology 62(5). American Academy of Neurology. Retrieved from mdconsult.com 9. Mettler, F. (2005). Essentials of Radiology, second edition. Page 149. Elsevier, Inc. Retrieved from mdconsult.com 10. Purvin, V. (2004). Cerebrovascular disease and the visual system. Ophthalmol Clin North Am, 17(3), Retrieved from mdconsult.com 11. Rowe, V. Tucker, S. (2004). Advances in vascular imaging. Surg Clin North Am, 84(5), Retrieved from mdconsult.com 14

15 12. Shah, K., Edlow, J. (2004). Transient ischemic attack: Review for the emergency physician. Annals of Emergency Medicine 43(5). Retrieved from mdconsult.com 13. Society for Vascular Ultrasound Professional performance guidelines. (2003). Transcranial doppler (non-imaging). Retrieved from SVUNET.com Open Meetings Part B MAC Contractor Advisory Committee (CAC) Meetings 14. Tusa, R. (2003). Dizziness. Med Clin North Am, 87(3), Retrieved from mdconsult.com Meeting Date Meeting Date 06/01/2017 Meeting Information State Meeting Information Noridian Healthcare Solutions, Room W3, nd Street S. Fargo, ND /29/2017 Anchorage Alaska 06/20/2017 Pheonix Arizona 06/21/2017 Boise Idaho 06/14/2017 Teleconference and in person in Cheyenne State Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming Montana, Wyoming 06/07/2017 Fargo North Dakota 06/24/2017 Portland Oregon 06/08/2017 Sioux Falls South Dakota 06/22/2017 Salt Lake City Utah 06/20/2017 Renton Washington Comment Period 06/01/2017 Start Date Comment Period 08/14/2017 End Date Released to Final Not yet released. LCD Date Reason(s) for Creation of Uniform LCDs Within a MAC Jurisdiction Proposed LCD 15

16 Proposed LCD Contact Coding Information Noridian Healthcare Solutions, LLC JF Part B Contractor Medical Director(s) Attention: Draft LCD Comments PO Box 6781 Fargo, North Dakota policydraft@noridian.com Bill Type Codes Revenue Codes CPT/HCPCS Codes Does the CPT 30% Coding Rule Apply? ICD-10 Codes that Support Medical Necessity Note: Performance is 012x 013x 014x 021x 022x 023x 071x 085x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Hospital - Laboratory Services Provided to Nonpatients Skilled Nursing - Inpatient (Including Medicare Part A) Skilled Nursing - Inpatient (Medicare Part B only) Skilled Nursing - Outpatient Clinic - Rural Health Critical Access Hospital 030X Laboratory - General Classification 0920 Other Diagnostic Services - General Classification 0921 Other Diagnostic Services - Peripheral Vascular Lab 0929 Other Diagnostic Services - Other Diagnostic Service Group 1: Paragraph Group 1: Codes DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED STUDY No Group 1: Paragraph Group 1: Codes G45.0 Vertebro-basilar artery syndrome 16

17 optimized by using code ranges. G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.3 Amaurosis fugax G45.8 Other transient cerebral ischemic attacks and related syndromes G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome H34.00 Transient retinal artery occlusion, unspecified eye H34.01 Transient retinal artery occlusion, right eye H34.02 Transient retinal artery occlusion, left eye H34.03 Transient retinal artery occlusion, bilateral H34.10 Central retinal artery occlusion, unspecified eye H34.11 Central retinal artery occlusion, right eye H34.12 Central retinal artery occlusion, left eye H34.13 Central retinal artery occlusion, bilateral H Partial retinal artery occlusion, right eye H Partial retinal artery occlusion, left eye H Partial retinal artery occlusion, bilateral H Partial retinal artery occlusion, unspecified eye H Retinal artery branch occlusion, right eye H Retinal artery branch occlusion, left eye H Retinal artery branch occlusion, bilateral H Retinal artery branch occlusion, unspecified eye H34.9 Unspecified retinal vascular occlusion H Transient visual loss, right eye H Transient visual loss, left eye H Transient visual loss, bilateral H Transient visual loss, unspecified eye H Sudden visual loss, right eye H Sudden visual loss, left eye H Sudden visual loss, bilateral H Sudden visual loss, unspecified eye I Cerebral infarction due to thrombosis of right carotid artery I Cerebral infarction due to thrombosis of left carotid artery 17

18 I I I I I I I I I I I63.30 I I I I I I I I I I Cerebral infarction due to thrombosis of bilateral carotid arteries Cerebral infarction due to thrombosis of unspecified carotid artery Cerebral infarction due to embolism of right carotid artery Cerebral infarction due to embolism of left carotid artery Cerebral infarction due to embolism of bilateral carotid arteries Cerebral infarction due to embolism of unspecified carotid artery stenosis of right carotid arteries stenosis of left carotid arteries stenosis of bilateral carotid arteries stenosis of unspecified carotid arteries Cerebral infarction due to thrombosis of unspecified cerebral artery Cerebral infarction due to thrombosis of right middle cerebral artery Cerebral infarction due to thrombosis of left middle cerebral artery Cerebral infarction due to thrombosis of bilateral middle cerebral arteries Cerebral infarction due to thrombosis of unspecified middle cerebral artery Cerebral infarction due to thrombosis of right anterior cerebral artery Cerebral infarction due to thrombosis of left anterior cerebral artery Cerebral infarction due to thrombosis of bilateral anterior arteries Cerebral infarction due to thrombosis of unspecified anterior cerebral artery Cerebral infarction due to thrombosis of right posterior cerebral artery Cerebral infarction due to thrombosis of left posterior cerebral artery 18

19 I I I I I I I63.39 I63.40 I I I I I I I I I I I I I Cerebral infarction to thrombosis of bilateral posterior arteries Cerebral infarction due to thrombosis of unspecified posterior cerebral artery Cerebral infarction due to thrombosis of right cerebellar artery Cerebral infarction due to thrombosis of left cerebellar artery Cerebral infarction to thrombosis of bilateral cerebellar arteries Cerebral infarction due to thrombosis of unspecified cerebellar artery Cerebral infarction due to thrombosis of other cerebral artery Cerebral infarction due to embolism of unspecified cerebral artery Cerebral infarction due to embolism of right middle cerebral artery Cerebral infarction due to embolism of left middle cerebral artery Cerebral infarction due to embolism of bilateral middle cerebral arteries Cerebral infarction due to embolism of unspecified middle cerebral artery Cerebral infarction due to embolism of right anterior cerebral artery Cerebral infarction due to embolism of left anterior cerebral artery Cerebral infarction due to embolism of bilateral anterior cerebral arteries Cerebral infarction due to embolism of unspecified anterior cerebral artery Cerebral infarction due to embolism of right posterior cerebral artery Cerebral infarction due to embolism of left posterior cerebral artery Cerebral infarction due to embolism of bilateral posterior cerebral arteries Cerebral infarction due to embolism of unspecified posterior cerebral artery Cerebral infarction due to embolism of right cerebellar artery 19

20 I I I I63.49 I63.50 I I I I I I I I I I I I I I I I Cerebral infarction due to embolism of left cerebellar artery Cerebral infarction due to embolism of bilateral cerebellar arteries Cerebral infarction due to embolism of unspecified cerebellar artery Cerebral infarction due to embolism of other cerebral artery stenosis of unspecified cerebral artery stenosis of right middle cerebral artery stenosis of left middle cerebral artery stenosis of bilateral middle arteries stenosis of unspecified middle cerebral artery stenosis of right anterior cerebral artery stenosis of left anterior cerebral artery stenosis of bilateral anterior arteries stenosis of unspecified anterior cerebral artery stenosis of right posterior cerebral artery stenosis of left posterior cerebral artery stenosis of bilateral posterior arteries stenosis of unspecified posterior cerebral artery stenosis of right cerebellar artery stenosis of left cerebellar artery stenosis of bilateral cerebellar arteries stenosis of unspecified cerebellar artery 20

21 I63.59 stenosis of other cerebral artery I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified I65.21 Occlusion and stenosis of right carotid artery I65.22 Occlusion and stenosis of left carotid artery I65.23 Occlusion and stenosis of bilateral carotid arteries I65.29 Occlusion and stenosis of unspecified carotid artery I65.8 Occlusion and stenosis of other precerebral arteries I66.01 Occlusion and stenosis of right middle cerebral artery I66.02 Occlusion and stenosis of left middle cerebral artery I66.03 Occlusion and stenosis of bilateral middle cerebral arteries I66.09 Occlusion and stenosis of unspecified middle cerebral artery I66.11 Occlusion and stenosis of right anterior cerebral artery I66.12 Occlusion and stenosis of left anterior cerebral artery I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries I66.19 Occlusion and stenosis of unspecified anterior cerebral artery I66.21 Occlusion and stenosis of right posterior cerebral artery I66.22 Occlusion and stenosis of left posterior cerebral artery I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries I66.29 Occlusion and stenosis of unspecified posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries I66.8 Occlusion and stenosis of other cerebral arteries I66.9 Occlusion and stenosis of unspecified cerebral artery I Reversible cerebrovascular vasoconstriction syndrome 21

22 I Other cerebrovascular vasospasm and vasoconstriction I67.89 Other cerebrovascular disease I72.0 Aneurysm of carotid artery I72.5 Aneurysm of other precerebral arteries I72.6 Aneurysm of vertebral artery I77.71 Dissection of carotid artery I77.74 Dissection of vertebral artery I77.75 Dissection of other precerebral arteries M31.5 Giant cell arteritis with polymyalgia rheumatica M31.6 Other giant cell arteritis R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems R22.0* Localized swelling, mass and lump, head R22.1* Localized swelling, mass and lump, neck R55 Syncope and collapse S15.001A Unspecified injury of right carotid artery, initial S15.001D Unspecified injury of right carotid artery, subsequent S15.001S Unspecified injury of right carotid artery, sequela S15.002A Unspecified injury of left carotid artery, initial S15.002D Unspecified injury of left carotid artery, subsequent S15.002S Unspecified injury of left carotid artery, sequela S15.009A Unspecified injury of unspecified carotid artery, initial S15.009D Unspecified injury of unspecified carotid artery, subsequent S15.009S Unspecified injury of unspecified carotid artery, sequela S15.011A Minor laceration of right carotid artery, initial S15.011D Minor laceration of right carotid artery, subsequent S15.011S Minor laceration of right carotid artery, sequela S15.012A Minor laceration of left carotid artery, initial 22

23 S15.012D S15.012S S15.019A S15.019D S15.019S S15.021A S15.021D S15.021S S15.022A S15.022D S15.022S S15.029A S15.029D S15.029S S15.091A S15.091D S15.091S S15.092A S15.092D S15.092S S15.099A S15.099D Minor laceration of left carotid artery, subsequent Minor laceration of left carotid artery, sequela Minor laceration of unspecified carotid artery, initial Minor laceration of unspecified carotid artery, subsequent Minor laceration of unspecified carotid artery, sequela Major laceration of right carotid artery, initial Major laceration of right carotid artery, subsequent Major laceration of right carotid artery, sequela Major laceration of left carotid artery, initial Major laceration of left carotid artery, subsequent Major laceration of left carotid artery, sequela Major laceration of unspecified carotid artery, initial Major laceration of unspecified carotid artery, subsequent Major laceration of unspecified carotid artery, sequela Other specified injury of right carotid artery, initial Other specified injury of right carotid artery, subsequent Other specified injury of right carotid artery, sequela Other specified injury of left carotid artery, initial Other specified injury of left carotid artery, subsequent Other specified injury of left carotid artery, sequela Other specified injury of unspecified carotid artery, initial Other specified injury of unspecified carotid artery, subsequent 23

24 ICD-10 Codes that DO NOT Support Medical Necessity Note: Performance is optimized by using code ranges. Additional ICD-10 Information Associated Documents Other specified injury of unspecified carotid artery, S15.099S sequela Encounter for preprocedural cardiovascular Z examination Z Encounter for other preprocedural examination Encounter for follow-up examination after Z09 completed treatment for conditions other than malignant neoplasm Group 1: Asterisk * Use this code to report pulsatile neck mass. Group 1: Paragraph Group 1: Codes Attachments Related Local Coverage Documents Related National Coverage Documents There are no attachments for this LCD. This LCD version has no Related Local Coverage Documents. This LCD version has no Related National Coverage Documents. 24