Noninvasive Peripheral Venous Studies

Transcription

1 Nninvasive Peripheral Venus Studies Nridian Healthcare Slutins, LLC Please Nte: This is a Prpsed LCD. Prpsed LCDs are wrks in prgress and nt necessarily a reflectin f the current plicies r practices. Prpsed LCDs in an apprval status display n the CMS MCD fr public review. Cntractr Infrmatin Cntractr Name Nridian Healthcare Slutins, LLC Cntract Number Cntract Type A and B MAC Assciated Cntract Numbers Prpsed LCD Infrmatin (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC, (A and B MAC J - F) Nridian Healthcare Slutins, LLC 1

2 Prpsed LCD ID Prpsed LCD Versin Prpsed LCD Title DL Nninvasive Peripheral Venus Studies CPT nly cpyright American Medical Assciatin. All rights reserved. AMA CPT ADA CDT AHA NUBC Cpyright Statements CDT nly cpyright 2016 American Dental Assciatin. All rights reserved. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is cpyrighted by American Hspital Assciatin ("AHA"), Chicag, Illinis. N prtin f OFFICIAL UB-04 MANUAL may be reprduced, srted in a retrieval system, r transmitted, in any frm r by any means, electrnic, mechanical, phtcpying, recrding r therwise, withut prir express, written cnsent f AHA. Health Frum reserves the right t change the cpyright ntice frm time t time upn written ntice t Cmpany. Scial Security Act (Title XVIII) Standard References: Title XVIII f the Scial Security Act, Sectin 1862(a)(1)(A) states that n Medicare payment shall be made fr items r services which are nt reasnable and necessary fr the diagnsis r treatment f illness r injury. CMS Natinal Cverage Plicy Title XVIII f the Scial Security Act, Sectin 1862(a)(7). This sectin excludes rutine physical examinatins. Title XVIII f the Scial Security Act, Sectin 1833(e) states that n payment shall be made t any prvider fr any claim that lacks the necessary infrmatin t prcess the claim. 2

3 Title XVIII f the Scial Security Act, Sectin 1862(a)(1)(D) states that n payment shall be made fr any services that are cnsidered investigatinal r experimental. IOM and Regulatin Citatins CMS Manual System, Publicatin , Medicare Benefit Plicy Manual, Chapter 15, ,addresses requirements fr rdering and fllwing rders fr diagnstic tests. Transmittal 94, Change Request 6100, Dated August 29, 2008, , addresses physician signature requirements fr diagnstic tests. CMS IOM Publicatin ,Medicare Natinal Cverage Determinatins Manual, Chapter 1, Sectins and CMS IOM Publicatin ,Medicare Claims Prcessing Manual, Chapter 23, Sectin 10 Reprting ICD Diagnsis and Prcedure cdes. CMS Manual System, Publicatin ,Medicare Prgram Integrity Manual, Chapter 3, , Diagnsis Cde Requirement. CMS IOM Publicatin ,Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual, Chapter 5 Crrect Cding Initiative. The Cde f Federal Regulatins (CFR), 42 CFR Specifies that all diagnstic tests must be rdered by the physician wh is treating the beneficiary. 3

4 The Cde f Federal Regulatins (CFR), 42 CFR (k)(1). States any services that are nt reasnable and necessary are excluded frm cverage. Jurisdictin Arizna Super MAC J - F Jurisdictin Cverage Guidance Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier. Cmpliance with the prvisins in this plicy may be mnitred and addressed thrugh pst payment data analysis and subsequent medical review audits. Cverage Indicatins, Limitatins and/r Medical Necessity Histry/Backgrund and/r General Infrmatin Nn-invasive vascular diagnstic studies utilize ultrasnic Dppler and physilgic principles t assess irregularities in bld flw in the venus system. Vascular studies include patient care required t perfrm the studies, supervisin f the studies and interpretatin f study results with cpies fr patient recrds f hard cpy utput with analysis f all data, including bidirectinal vascular flw r imaging when prvided. (AMA 2016 CPT bk, page 626). A hard cpy, r a sft cpy cnvertible t a hard cpy, prvides a permanent recrd f the study perfrmed and must be f a quality that meets accepted radilgic standards. A duplex scan (CPT cdes and 93971) cmbines Dppler spectrum analysis and cnventinal ultrasund, t visualize the structure f bld vessels, hw the bld is flwing thrugh the vessels, and whether there is any bstructin in the vessels. A nn-invasive physilgic study implies functinal measurement prcedures including Dppler wavefrm analysis, bld pressure measurements, r plethysmgraphy. Plethysmgraphy implies vlume measurement prcedures including air, impedance, r strain gauge methds. Fr cding guidelines, please refer t 4

5 Lcal Cverage Article A55529 Cding Guidelines: Nn-Invasive Peripheral Venus Studies. Cvered Indicatins 1. Deep Vein Thrmbsis (DVT) Due t the risk f DVT assciated with pulmnary emblism (PE), bjective testing f venus functin is cnsidered reasnable and necessary in patients that are candidates fr anticagulatin r invasive therapeutic prcedures fr any ne f the fllwing: T evaluate clinical signs r symptms suggestive f acute r new nset DVT such as extremity swelling, tenderness, inflammatin r erythema. Investigatin fr DVT as the surce f a suspected r cnfirmed pulmnary emblism. Evaluatin f unexplained extremity edema, especially unilateral r asymmetric, in an individual at risk fr DVT (e.g., immbile, status-pst majr surgical prcedure, indwelling vascular catheter r prsthesis, r pstpartum). Bilateral r symmetric limb edema is mre likely t result frm a systemic disrder (e.g. cngestive heart failure, hypalbuminemia, arthritis) r certain drugs. Therefre, bilateral limb edema is cnsidered reasnable and necessary fr venus studies in individuals at risk fr DVT when there is n therwise plausible cause. Fllw-up fr patients with knwn venus thrmbsis t mnitr fr prgressin, determine curse f treatment r the need t alter treatment based n new symptms. 2. Chrnic Venus Insufficiency 5

6 Chrnic venus insufficiency is impaired venus return which may cause lwer extremity symptms. Objective testing f venus functin is cnsidered reasnable and necessary in patients that are candidates fr anticagulatin r invasive therapeutic prcedures fr any ne f the fllwing: Evaluatin f Pstthrmbtic (Pstphlebitic) Syndrme (PTS) in patients with symptms f PTS (e.g. chrnic leg pain, leg heaviness, leg swelling, leg itching r ulcers n the leg). Evaluatin f suspected valvular incmpetence in patients with symptmatic chrnic venus insufficiency r symptmatic varicse veins (e.g. significant pain r edema f the lwer leg, ulceratin, thickening and disclratin) suspected t be secndary t venus insufficiency in rder t cnfirm this diagnsis prir t treatment. Pst-prcedural assessment f venus ablatin. If a great r small saphenus vein underges ablatin, a duplex scan f the affected side (CPT cde 93971) is cnsidered reasnable and necessary pstperatively within 72 hurs after the prcedure, t assess the result f the surgery and the pssibility f prpagatin f a thrmbus. Nte: Use ICD-10-CM cde Z09 nly t describe a limited venus duplex (CPT cde 93971) perfrmed within 72 hurs f a saphenus vein ablatin prcedure (CPT cdes 36475, 36476, 36478, r 36479). Nte: Additinal cverage infrmatin pertinent t the treatment f varicse veins and ablatin therapy is lcated in LCD L37291, Treatment f Varicse Veins Disease f the Lwer Extremities. 3. Preperative Examinatins Nn-Invasive Peripheral Venus Studies are cnsidered reasnable and necessary fr select preperative examinatins that meet criteria fr cverage as fllws: 6

7 Bypass surgery- Duplex scan f extremity veins including respnses t cmpressin and ther maneuvers; unilateral r limited study (CPT cde 93971) is indicated fr the preperative examinatin f ptential harvest vein grafts t be utilized during bypass surgery. This service is cnsidered reasnable and necessary when the results f the study are needed t lcate suitable graft vessels. The need fr bypass surgery must be determined prir t perfrmance f the test. Hemdialysis access surgery-vessel mapping fr hemdialysis (HCPCS cde G0365) is indicated fr the preperative examinatin f vessels prir t hemdialysis access site surgery in patients with end stage renal disease (ESRD). This service is cnsidered reasnable and necessary when the results f the study are needed t determine apprpriate vessel utilizatin (i.e., when the patient s clinical evaluatin des nt readily lead t the selectin f a vein that is suitable fr creating a dialysis fistula). The need fr a hemdialysis access site must be determined prir t perfrmance f the test. Limitatins 1. Objective testing f peripheral venus functin is cnsidered nt reasnable and necessary and therefre nn- cvered fr any ne f the fllwing: Asymptmatic varicse veins Rutine screening tests Nte: ICD-10-CM diagnsis cde Z13.9 (special screening f ther cnditins, unspecified cnditin) shuld be used t indicate screening tests perfrmed in the absence f a specific sign, symptm, r cmplaint. Use f ICD-10-CM cde Z13.9 will result in the denial f claims as nn-cvered screening services. 7

8 When the evaluatin, management and treatment f the varicse vein are cnsidered t be csmetic nly, billing fr these services will be denied as csmetic. 2. Nn-invasive vascular studies are cnsidered nt reasnable and necessary if the results are nt needed fr clinical decisin making. If the study results will have n impact n the decisin fr further diagnstic r therapeutic prcedures r will nt prvide any unique diagnstic infrmatin that wuld impact patient management, then the nn-invasive studies are nt reasnable and necessary. Fr example, if it is evident frm the findings f the histry and physical examinatin that the patient is ging t prceed t angigraphy, then nn-invasive vascular studies are nt reasnable and necessary. 3. The fllwing limitatins apply t multiple nn-invasive studies n the same encunter r same day: Perfrmance f bth nn-invasive extracranial arterial studies (CPT cdes r 93882) and nn- invasive evaluatin f extremity veins (CPT cdes r 93971) during the same encunter is rarely medically necessary. Dcumentatin must clearly supprt the medical necessity if bth prcedures are perfrmed during the same encunter, and be made available upn request. Because signs and symptms f arterial cclusive disease and venus disease are s divergent, the perfrmance f simultaneus arterial and venus studies during the same encunter is rarely medically necessary. Cnsequently, dcumentatin must clearly supprt the medical necessity f bth prcedures if perfrmed during the same encunter, and be made available upn request. It is rarely medically necessary t perfrm lwer extremity and upper extremity studies n the same day. Dcumentatin must clearly supprt the medical necessity 8

9 f bth upper and lwer extremities if perfrmed n the same day, and be made available upn request. 4. "The use f a simple hand-held r ther Dppler device that des nt prduce hard cpy data r that prduces a recrd that des nt permit analysis f bidirectinal vascular flw, is cnsidered t be part f the physical examinatin f the vascular system and is nt separately reprted. (AMA 2016 CPT Bk, Page 626) Dppler prcedures perfrmed with zer-crssers (i.e., analg [strip chart recrder] analysis) are als included in any ther E/M service. Therefre, it is nt reasnable and necessary t reprt these prcedures as separate services. 5. Accrding t NCD 20.14, the fllwing methds are nt cvered: Mechanical Oscillmetry Inductance Plethysmgraphy Capacitance Plethysmgraphy Phtelectric Plethysmgraphy Training Requirements/Certificatins The accuracy f nn-invasive diagnstic testing studies depends n the knwledge, skill and experience f the physician and/r technlgist perfrming and interpreting the study. Dcumentatin f applicable training and experience must be maintained and made available upn request. Services will be cnsidered reasnable and necessary nly if perfrmed by apprpriately trained persnnel. All nn-invasive vascular studies must be: 9

10 1. Perfrmed by a qualified physician; r 2. Perfrmed under the general supervisin f a qualified physician by a licensed* technlgist wh is certified in vascular technlgy; r 3. Perfrmed in an accredited vascular labratry *State licensure fr a technlgist is required in additin t apprpriate recgnized certificatin. Dcumentatin f current, active licensure must be maintained and made available upn request. In the absence f a state/federal district licensing bard, the requirement fr licensure is waived. A qualified physician fr this service/prcedure is defined as: A. Physician is prperly enrlled in Medicare; and B. Training and expertise must have been acquired within the framewrk f an accredited residency and/r fellwship prgram in the applicable specialty/subspecialty in the United States r must reflect equivalent educatin, training, and expertise endrsed by an academic institutin in the United States and/r by the applicable specialty/subspecialty sciety in the United States. General Supervisin means the prcedure is furnished under the physician's verall directin and cntrl, but the physician's presence is nt required during the perfrmance f the prcedure. Under General Supervisin, the training f the nn-physician persnnel wh actually perfrms the diagnstic prcedure and the maintenance f the necessary equipment and supplies are the cntinuing respnsibility f the physician. Ntice: This LCD impses frequency limitatins as well as diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr medical necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatins, and all Medicare payment rules. 10

11 Fr frequency limitatins please refer t the Utilizatin Guidelines sectin belw. As published in CMS IOM , Chapter 13, Sectin , in rder t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under Sectin 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000 that meet the requirements f the Clinical Trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient's cnditin r t imprve the functin f a malfrmed bdy member. Furnished in a setting apprpriate t the patient's medical needs and cnditin. Ordered and furnished by qualified persnnel. 11

12 One that meets, but des nt exceed, the patient's medical needs. At least as beneficial as an existing and available medically apprpriate alternative. The redeterminatin prcess may be utilized fr cnsideratin f services perfrmed utside f the reasnable and necessary requirements in this LCD. Prpsed Prcess Infrmatin Synpsis f Changes Assciated Infrmatin Fields Changes Changed Nt Applicable Dcumentatin Requirements 1. All dcumentatin must be maintained in the patient s medical recrd and made available t the cntractr upn request. 12

13 2. Every page f the recrd must be legible and include apprpriate patient identificatin infrmatin (e.g., cmplete name, dates f service(s)). The dcumentatin must include the legible signature f the physician r nn-physician practitiner respnsible fr and prviding the care t the patient. 3. The submitted medical recrd shuld supprt the use f the selected ICD-10-CM cde(s). The submitted CPT/HCPCS cde shuld describe the service perfrmed. 4. The medical recrd dcumentatin must supprt the medical necessity f the services as directed in this plicy. 5. The medical necessity fr perfrming bth nn-invasive extracranial arterial studies (CPT cdes r 93882) and nn-invasive evaluatin f extremity veins (CPT cdes r 93971) during the same encunter must be clearly dcumented in the medical recrd. 6. The medical necessity fr perfrming simultaneus arterial and venus studies during the same encunter must be clearly dcumented in the medical recrd. 7. The medical necessity f perfrming lwer extremity and upper extremity studies n the same day must be clearly dcumented in the medical recrd. Utilizatin Guidelines In accrdance with CMS Ruling 95-1 (V), utilizatin f these services shuld be cnsistent with lcally acceptable standards f practice. Only ne preperative scan (CPT cde 93971) is cnsidered reasnable and necessary fr bypass surgery. 13

14 Only ne preperative scan (HCPCS cde G0365) is cnsidered reasnable and necessary per hemdialysis access site surgery. Only ne limited study (CPT cde 93971) is cnsidered reasnable and necessary pst peratively within 72 hurs f a saphenus vein ablatin, whether surgery is perfrmed n ne side r bilaterally. One Dppler ultrasund study r duplex scan will be cvered fr dcumentatin f disease and mapping fr chrnic venus insufficiency r symptmatic varicse veins. Ntice: This LCD impses utilizatin guideline limitatins. Despite Medicare allwing up t these maximums, each patient s cnditin and respnse t treatment must medically warrant the number f services reprted fr payment. Medicare requires the medical necessity fr each service reprted t be clearly demnstrated in the patient s medical recrd. Medicare expects that patients will nt rutinely require the maximum allwable number f services. 1. ACR-AIUM-SPR-SRU Practice Parameter fr the Perfrmance f Peripheral Venus Ultrasund Examinatin. American Cllege f Radilgy. Revised 2015 (Reslutin 33). Surces f Infrmatin and Basis fr Decisin 2. Duketis JD. Chrnic Venus Insufficiency and Pstphlebitic Syndrme. Merck Manual prfessinal versin nline last revised May 2014: disrders/chrnic-venus-insufficiencyand-pstphlebitic-syndrme. 3. Eskandari MK, Pearce WH, Ya J. Current Vascular Surgery Sheltn, CT: Peple s Medical Publishing Huse USA, Accessed nline n August 18,

15 4. Harlander-Lcke M, Jimenez JC, Lawrence PF, et al. Management f endvenus heat-induced thrmbus using a classificatin system and treatment algrithm fllwing segmental thermal ablatin f the small saphenus vein. Jurnal f Vascular Surgery, August 2013;58(2): Khilnani NM, Grassi CJ, Kundu S, et al. Multi-sciety Cnsensus Quality Imprvement Guidelines fr the Treatment f Lwer-extremity Superficial Venus Insufficiency with Endvenus Thermal Ablatin frm the Sciety f Interventinal Radilgy, Cardivascular Interventinal Radilgical Sciety f Eurpe, American Cllege f Pheblgy, and Canadian Interventinal Radilgy Assciatin. J Vasc Interv Radil 2010;21: Lawrence, Peter F et al, Classificatin f prximal endvenus clsure levels and treatment algrithm. Jurnal f Vascular Surgery. August 2010, Vl 52 (2): Luckraz H, Lwe J, Pugh N, et al. Pre-perative lng saphenus vein mapping predicts vein anatmy and quality leading t imprved pstperative leg mrbidity. Interactive Cardivascular and Thracic Surgery ; Office f Inspectr General DHHS, Medicare Part B Billing fr Vascular Ultrasund. OEI July Stanley, D. (2004). The imprtance f Interscietal Cmmissin fr the accreditatin f vascular labratries (ICAVL) certificatin fr nninvasive peripheral vascular tests: The Tennessee experience. The Jurnal fr Vascular Ultrasund, 28(2),

16 10. Vazquez, SR, Kahn, SR. Pstthrmbtic Syndrme. Circulatin. 2010;121:e217-e Grnik HL, Gerhard-Herman MD, Misra S, Mhler ER III, Zierler RE. ACCF/ACR/AIUM/ASE/ASN/IAC/SCAI/SCCT/SIR/SVM/SVS 2013 apprpriate use criteria fr peripheral vascular ultrasund and physilgical testing part II: testing fr venus disease and evaluatin f hemdialysis access: a reprt f the American Cllege f Cardilgy Fundatin Apprpriate Use Criteria Task Frce, the American Cllege f Radilgy, American Institute f Ultrasund in Medicine, American Sciety f Echcardigraphy, American Sciety f Nephrlgy, Interscietal Accreditatin Cmmissin, Sciety fr Cardivascular Angigraphy and Interventins, Sciety f Cardivascular Cmputed Tmgraphy, Sciety f Interventinal Radilgy, Sciety fr Vascular Medicine, Sciety fr Vascular Medicine, Sciety fr Vascular Surgery. J Am Cll Cardil 2013;62: Other Cntractr Plicies L35451, Nn-Invasive Peripheral Venus Studies, Nvitas Slutins Jurisdictins H and L Lcal Cverage Determinatin L33693, Nn-Invasive Evaluatin f Extremity Veins, First Cast Service Optins Jurisdictin N Lcal Cverage Determinatin L34229, Nninvasive Peripheral Venus Studies, Nridian Healthcare Slutins Jurisdictin E Lcal Cverage Determinatin L33627, Nn-Invasive Vascular Studies, Natinal Gvernment Services Jurisdictin K Lcal Cverage Determinatin 16

17 Open Meetings Part B MAC Cntractr Advisry Cmmittee (CAC) Meetings Cmment Perid Start Date Cmment Perid End Date Released t Final LCD Date Reasn(s) fr Prpsed LCD Prpsed LCD Cntact Meeting Date 06/01/2017 Meeting Infrmatin Nridian Healthcare Slutins Rm W nd Street S Farg, ND State Alaska, Arizna, Idah, Mntana, Nrth Dakta, Oregn, Suth Dakta, Utah, Washingtn, Wyming Meeting Date Meeting Infrmatin State 06/29/2017 Anchrage Alaska 06/20/2017 Phenix Arizna 06/21/2017 Bise Idah 06/14/2017 Telecnference and in persn Cheyenne Mntana, Wyming 06/07/2017 Farg Nrth Dakta 06/24/2017 Prtland Oregn 06/08/2017 Siux Falls Suth Dakta 06/22/2017 Salt Lake City Utah 06/20/2017 Rentn Washingtn 06/01/ /14/2017 Cding Infrmatin Nt yet released. Creatin f Unifrm LCDs Within a MAC Jurisdictin Nridian Healthcare Slutins, LLC JF Part B Cntractr Medical Directr(s) Attentin: Draft LCD Cmments PO Bx 6781 Farg, Nrth Dakta plicydraft@nridian.cm 17

18 Bill Type Cdes Revenue Cdes CPT/HCPCS Cdes 011x Hspital Inpatient (Including Medicare Part A) 012x Hspital Inpatient (Medicare Part B nly) 013x Hspital Outpatient 018x Hspital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B nly) 023x Skilled Nursing - Outpatient 028x Skilled Nursing - Swing Beds 083x Ambulatry Surgery Center 085x Critical Access Hspital Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry. Unless specified in the plicy, services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: The cntractr has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed. CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM) Pub , Medicare Claims Prcessing Manual, fr further guidance Other Diagnstic Services - Peripheral Vascular Lab Grup 1: Paragraph Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. Grup 1: Cdes DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 18

19 Grup 2: Paragraph N/A Grup 2: Cdes VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES FOR PREOPERATIVE VESSEL MAPPING PRIOR TO G0365 CREATION OF HEMODIALYSIS ACCESS USING AN AUTOGENOUS HEMODIALYSIS CONDUIT, INCLUDING ARTERIAL INFLOW AND VENOUS OUTFLOW) Des the CPT 30% Cding Rule N Apply? Grup 1: Paragraph It is the prvider s respnsibility t select cdes carried ut t the highest level f specificity and selected frm the ICD-10-CM cde bk apprpriate t the year in which the service is rendered fr the claim(s) submitted. Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes and 93971: Cvered fr: Grup 1: Cdes I26.01 Septic pulmnary emblism with acute cr pulmnale Saddle emblus f pulmnary artery with acute cr I26.02 pulmnale ICD-10 Cdes that Supprt Medical Necessity Nte: Perfrmance is ptimized by using cde ranges. I26.09 Other pulmnary emblism with acute cr pulmnale I26.90 Septic pulmnary emblism withut acute cr pulmnale I26.92 Saddle emblus f pulmnary artery withut acute cr pulmnale I26.99 Other pulmnary emblism withut acute cr pulmnale I74.9* Emblism and thrmbsis f unspecified artery I80.01 Phlebitis and thrmbphlebitis f superficial vessels f right lwer extremity I80.02 Phlebitis and thrmbphlebitis f superficial vessels f left lwer extremity I80.03 Phlebitis and thrmbphlebitis f superficial vessels f lwer extremities, bilateral I80.11 Phlebitis and thrmbphlebitis f right femral vein I80.12 Phlebitis and thrmbphlebitis f left femral vein I80.13 Phlebitis and thrmbphlebitis f femral vein, bilateral I Phlebitis and thrmbphlebitis f right iliac vein I Phlebitis and thrmbphlebitis f left iliac vein 19

20 I Phlebitis and thrmbphlebitis f iliac vein, bilateral I Phlebitis and thrmbphlebitis f right ppliteal vein I Phlebitis and thrmbphlebitis f left ppliteal vein I Phlebitis and thrmbphlebitis f ppliteal vein, bilateral I Phlebitis and thrmbphlebitis f right tibial vein I Phlebitis and thrmbphlebitis f left tibial vein I Phlebitis and thrmbphlebitis f tibial vein, bilateral I Phlebitis and thrmbphlebitis f ther deep vessels f right lwer extremity I Phlebitis and thrmbphlebitis f ther deep vessels f left lwer extremity I Phlebitis and thrmbphlebitis f ther deep vessels f lwer extremity, bilateral I80.8 Phlebitis and thrmbphlebitis f ther sites I82.1 Thrmbphlebitis migrans I Acute emblism and thrmbsis f inferir vena cava I Acute emblism and thrmbsis f right femral vein I Acute emblism and thrmbsis f left femral vein I Acute emblism and thrmbsis f femral vein, bilateral I Acute emblism and thrmbsis f right iliac vein I Acute emblism and thrmbsis f left iliac vein I Acute emblism and thrmbsis f iliac vein, bilateral I Acute emblism and thrmbsis f right ppliteal vein I Acute emblism and thrmbsis f left ppliteal vein I Acute emblism and thrmbsis f ppliteal vein, bilateral I Acute emblism and thrmbsis f right tibial vein I Acute emblism and thrmbsis f left tibial vein I Acute emblism and thrmbsis f tibial vein, bilateral I Acute emblism and thrmbsis f ther specified deep vein f right lwer extremity I Acute emblism and thrmbsis f ther specified deep vein f left lwer extremity I Acute emblism and thrmbsis f ther specified deep vein f lwer extremity, bilateral I Chrnic emblism and thrmbsis f right femral vein I Chrnic emblism and thrmbsis f left femral vein I Chrnic emblism and thrmbsis f femral vein, bilateral I Chrnic emblism and thrmbsis f right iliac vein 20

21 I Chrnic emblism and thrmbsis f left iliac vein I Chrnic emblism and thrmbsis f iliac vein, bilateral I Chrnic emblism and thrmbsis f right ppliteal vein I Chrnic emblism and thrmbsis f left ppliteal vein I Chrnic emblism and thrmbsis f ppliteal vein, bilateral I Chrnic emblism and thrmbsis f right tibial vein I Chrnic emblism and thrmbsis f left tibial vein I Chrnic emblism and thrmbsis f tibial vein, bilateral I Chrnic emblism and thrmbsis f ther specified deep vein f right lwer extremity I Chrnic emblism and thrmbsis f ther specified deep vein f left lwer extremity I Chrnic emblism and thrmbsis f ther specified deep vein f lwer extremity, bilateral I Acute emblism and thrmbsis f superficial veins f right upper extremity I Acute emblism and thrmbsis f superficial veins f left upper extremity I Acute emblism and thrmbsis f superficial veins f upper extremity, bilateral I Acute emblism and thrmbsis f deep veins f right upper extremity I Acute emblism and thrmbsis f deep veins f left upper extremity I Acute emblism and thrmbsis f deep veins f upper extremity, bilateral I Chrnic emblism and thrmbsis f superficial veins f right upper extremity I Chrnic emblism and thrmbsis f superficial veins f left upper extremity I Chrnic emblism and thrmbsis f superficial veins f upper extremity, bilateral I Chrnic emblism and thrmbsis f deep veins f right upper extremity I Chrnic emblism and thrmbsis f deep veins f left upper extremity I Chrnic emblism and thrmbsis f deep veins f upper extremity, bilateral I82.A11 Acute emblism and thrmbsis f right axillary vein I82.A12 Acute emblism and thrmbsis f left axillary vein 21

22 I82.A13 I82.A21 I82.A22 I82.A23 I82.C11 I82.C12 I82.C13 I82.C21 I82.C22 I82.C23 I I I Acute emblism and thrmbsis f axillary vein, bilateral Chrnic emblism and thrmbsis f right axillary vein Chrnic emblism and thrmbsis f left axillary vein Chrnic emblism and thrmbsis f axillary vein, bilateral Acute emblism and thrmbsis f right internal jugular vein Acute emblism and thrmbsis f left internal jugular vein Acute emblism and thrmbsis f internal jugular vein, bilateral Chrnic emblism and thrmbsis f right internal jugular vein Chrnic emblism and thrmbsis f left internal jugular vein Chrnic emblism and thrmbsis f internal jugular vein, bilateral Emblism and thrmbsis f superficial veins f right lwer extremities Emblism and thrmbsis f superficial veins f left lwer extremities Emblism and thrmbsis f superficial veins f lwer extremities, bilateral I Acute emblism and thrmbsis f ther specified veins I Chrnic emblism and thrmbsis f ther specified veins I Varicse veins f right lwer extremity with ulcer f thigh I Varicse veins f right lwer extremity with ulcer f calf I Varicse veins f right lwer extremity with ulcer f ankle I Varicse veins f right lwer extremity with ulcer f heel and midft I Varicse veins f right lwer extremity with ulcer ther part f ft I Varicse veins f right lwer extremity with ulcer ther part f lwer leg I Varicse veins f left lwer extremity with ulcer f thigh I Varicse veins f left lwer extremity with ulcer f calf I Varicse veins f left lwer extremity with ulcer f ankle I Varicse veins f left lwer extremity with ulcer f heel and midft I Varicse veins f left lwer extremity with ulcer ther part f ft 22

23 I Varicse veins f left lwer extremity with ulcer ther part f lwer leg I83.11 Varicse veins f right lwer extremity with inflammatin I83.12 Varicse veins f left lwer extremity with inflammatin I Varicse veins f right lwer extremity with bth ulcer f thigh and inflammatin I Varicse veins f right lwer extremity with bth ulcer f calf and inflammatin I Varicse veins f right lwer extremity with bth ulcer f ankle and inflammatin I Varicse veins f right lwer extremity with bth ulcer f heel and midft and inflammatin I Varicse veins f right lwer extremity with bth ulcer ther part f ft and inflammatin I Varicse veins f right lwer extremity with bth ulcer f ther part f lwer extremity and inflammatin I Varicse veins f left lwer extremity with bth ulcer f thigh and inflammatin I Varicse veins f left lwer extremity with bth ulcer f calf and inflammatin I Varicse veins f left lwer extremity with bth ulcer f ankle and inflammatin I Varicse veins f left lwer extremity with bth ulcer f heel and midft and inflammatin I Varicse veins f left lwer extremity with bth ulcer ther part f ft and inflammatin I Varicse veins f left lwer extremity with bth ulcer f ther part f lwer extremity and inflammatin I Varicse veins f right lwer extremities with pain I Varicse veins f left lwer extremities with pain I Varicse veins f bilateral lwer extremities with pain I Varicse veins f right lwer extremities with ther cmplicatins I Varicse veins f left lwer extremities with ther cmplicatins I Varicse veins f bilateral lwer extremities with ther cmplicatins I Pstthrmbtic syndrme withut cmplicatins f right lwer extremity I Pstthrmbtic syndrme withut cmplicatins f left lwer extremity 23

24 I Pstthrmbtic syndrme withut cmplicatins f bilateral lwer extremity I Pstthrmbtic syndrme with ulcer f right lwer extremity I Pstthrmbtic syndrme with ulcer f left lwer extremity I Pstthrmbtic syndrme with ulcer f bilateral lwer extremity I Pstthrmbtic syndrme with inflammatin f right lwer extremity I Pstthrmbtic syndrme with inflammatin f left lwer extremity I Pstthrmbtic syndrme with inflammatin f bilateral lwer extremity I Pstthrmbtic syndrme with ulcer and inflammatin f right lwer extremity I Pstthrmbtic syndrme with ulcer and inflammatin f left lwer extremity I Pstthrmbtic syndrme with ulcer and inflammatin f bilateral lwer extremity I Pstthrmbtic syndrme with ther cmplicatins f right lwer extremity I Pstthrmbtic syndrme with ther cmplicatins f left lwer extremity I Pstthrmbtic syndrme with ther cmplicatins f bilateral lwer extremity I87.1 Cmpressin f vein I87.2 Venus insufficiency (chrnic) (peripheral) I Chrnic venus hypertensin (idipathic) with ulcer f right lwer extremity I Chrnic venus hypertensin (idipathic) with ulcer f left lwer extremity I Chrnic venus hypertensin (idipathic) with ulcer f bilateral lwer extremity I Chrnic venus hypertensin (idipathic) with inflammatin f right lwer extremity I Chrnic venus hypertensin (idipathic) with inflammatin f left lwer extremity I Chrnic venus hypertensin (idipathic) with inflammatin f bilateral lwer extremity 24

25 I Chrnic venus hypertensin (idipathic) with ulcer and inflammatin f right lwer extremity I Chrnic venus hypertensin (idipathic) with ulcer and inflammatin f left lwer extremity I Chrnic venus hypertensin (idipathic) with ulcer and inflammatin f bilateral lwer extremity I Chrnic venus hypertensin (idipathic) with ther cmplicatins f right lwer extremity I Chrnic venus hypertensin (idipathic) with ther cmplicatins f left lwer extremity I Chrnic venus hypertensin (idipathic) with ther cmplicatins f bilateral lwer extremity I96 Gangrene, nt elsewhere classified J80 Acute respiratry distress syndrme J96.00 Acute respiratry failure, unspecified whether with hypxia r hypercapnia J96.01 Acute respiratry failure with hypxia J96.02 Acute respiratry failure with hypercapnia J96.90 Respiratry failure, unspecified, unspecified whether with hypxia r hypercapnia L Nn-pressure chrnic ulcer f right thigh limited t breakdwn f skin L Nn-pressure chrnic ulcer f right thigh with fat layer expsed L Nn-pressure chrnic ulcer f right thigh with necrsis f muscle L Nn-pressure chrnic ulcer f right thigh with necrsis f bne L Nn-pressure chrnic ulcer f left thigh limited t breakdwn f skin L Nn-pressure chrnic ulcer f left thigh with fat layer expsed L Nn-pressure chrnic ulcer f left thigh with necrsis f muscle L Nn-pressure chrnic ulcer f left thigh with necrsis f bne L Nn-pressure chrnic ulcer f left thigh with unspecified severity L Nn-pressure chrnic ulcer f right calf limited t breakdwn f skin 25

26 L L L L L L L L L L L L L L L L L L L L L Nn-pressure chrnic ulcer f right calf with fat layer expsed Nn-pressure chrnic ulcer f right calf with necrsis f muscle Nn-pressure chrnic ulcer f right calf with necrsis f bne Nn-pressure chrnic ulcer f right calf with unspecified severity Nn-pressure chrnic ulcer f left calf limited t breakdwn f skin Nn-pressure chrnic ulcer f left calf with fat layer expsed Nn-pressure chrnic ulcer f left calf with necrsis f muscle Nn-pressure chrnic ulcer f left calf with necrsis f bne Nn-pressure chrnic ulcer f left calf with unspecified severity Nn-pressure chrnic ulcer f right ankle limited t breakdwn f skin Nn-pressure chrnic ulcer f right ankle with fat layer expsed Nn-pressure chrnic ulcer f right ankle with necrsis f muscle Nn-pressure chrnic ulcer f right ankle with necrsis f bne Nn-pressure chrnic ulcer f right ankle with unspecified severity Nn-pressure chrnic ulcer f left ankle limited t breakdwn f skin Nn-pressure chrnic ulcer f left ankle with fat layer expsed Nn-pressure chrnic ulcer f left ankle with necrsis f muscle Nn-pressure chrnic ulcer f left ankle with necrsis f bne Nn-pressure chrnic ulcer f left ankle with unspecified severity Nn-pressure chrnic ulcer f right heel and midft limited t breakdwn f skin Nn-pressure chrnic ulcer f right heel and midft with fat layer expsed 26

27 L L L L L L L L L L L L L L L L L L L L L Nn-pressure chrnic ulcer f right heel and midft with necrsis f muscle Nn-pressure chrnic ulcer f right heel and midft with necrsis f bne Nn-pressure chrnic ulcer f right heel and midft with unspecified severity Nn-pressure chrnic ulcer f left heel and midft limited t breakdwn f skin Nn-pressure chrnic ulcer f left heel and midft with fat layer expsed Nn-pressure chrnic ulcer f left heel and midft with necrsis f muscle Nn-pressure chrnic ulcer f left heel and midft with necrsis f bne Nn-pressure chrnic ulcer f left heel and midft with unspecified severity Nn-pressure chrnic ulcer f ther part f right ft limited t breakdwn f skin Nn-pressure chrnic ulcer f ther part f right ft with fat layer expsed Nn-pressure chrnic ulcer f ther part f right ft with necrsis f muscle Nn-pressure chrnic ulcer f ther part f right ft with necrsis f bne Nn-pressure chrnic ulcer f ther part f right ft with unspecified severity Nn-pressure chrnic ulcer f ther part f left ft limited t breakdwn f skin Nn-pressure chrnic ulcer f ther part f left ft with fat layer expsed Nn-pressure chrnic ulcer f ther part f left ft with necrsis f muscle Nn-pressure chrnic ulcer f ther part f left ft with necrsis f bne Nn-pressure chrnic ulcer f ther part f left ft with unspecified severity Nn-pressure chrnic ulcer f ther part f right lwer leg limited t breakdwn f skin Nn-pressure chrnic ulcer f ther part f right lwer leg with fat layer expsed Nn-pressure chrnic ulcer f ther part f right lwer leg with necrsis f muscle 27

28 L Nn-pressure chrnic ulcer f ther part f right lwer leg with necrsis f bne L Nn-pressure chrnic ulcer f ther part f right lwer leg with unspecified severity L Nn-pressure chrnic ulcer f ther part f left lwer leg limited t breakdwn f skin L Nn-pressure chrnic ulcer f ther part f left lwer leg with fat layer expsed L Nn-pressure chrnic ulcer f ther part f left lwer leg with necrsis f muscle L Nn-pressure chrnic ulcer f ther part f left lwer leg with necrsis f bne L Nn-pressure chrnic ulcer f ther part f left lwer leg with unspecified severity M71.21 Synvial cyst f ppliteal space [Baker], right knee M71.22 Synvial cyst f ppliteal space [Baker], left knee M Pain in right arm M Pain in left arm M Pain in right leg M Pain in left leg M Pain in right upper arm M Pain in left upper arm M Pain in right frearm M Pain in left frearm M Pain in right hand M Pain in left hand M Pain in right finger(s) M Pain in left finger(s) M Pain in right thigh M Pain in left thigh M Pain in right lwer leg M Pain in left lwer leg M Pain in right ft M Pain in left ft M Pain in right te(s) M Pain in left te(s) O22.21 Superficial thrmbphlebitis in pregnancy, first trimester O22.22 Superficial thrmbphlebitis in pregnancy, secnd trimester 28

29 O22.23 Superficial thrmbphlebitis in pregnancy, third trimester O22.31 Deep phlebthrmbsis in pregnancy, first trimester O22.32 Deep phlebthrmbsis in pregnancy, secnd trimester O22.33 Deep phlebthrmbsis in pregnancy, third trimester O87.0 Superficial thrmbphlebitis in the puerperium O87.1 Deep phlebthrmbsis in the puerperium O Thrmbemblism in pregnancy, first trimester O Thrmbemblism in pregnancy, secnd trimester O Thrmbemblism in pregnancy, third trimester O88.22 Thrmbemblism in childbirth O88.23 Thrmbemblism in the puerperium Q27.31 Arterivenus malfrmatin f vessel f upper limb Q27.32 Arterivenus malfrmatin f vessel f lwer limb Q27.8 Other specified cngenital malfrmatins f peripheral vascular system R04.2 Hemptysis R06.00 Dyspnea, unspecified R06.02 Shrtness f breath R06.09 Other frms f dyspnea R06.82 Tachypnea, nt elsewhere classified R07.1 Chest pain n breathing R07.81 Pleurdynia R07.82 Intercstal pain R07.89 Other chest pain R07.9 Chest pain, unspecified R22.31 Lcalized swelling, mass and lump, right upper limb R22.32 Lcalized swelling, mass and lump, left upper limb R22.33 Lcalized swelling, mass and lump, upper limb, bilateral R22.41 Lcalized swelling, mass and lump, right lwer limb R22.42 Lcalized swelling, mass and lump, left lwer limb R22.43 Lcalized swelling, mass and lump, lwer limb, bilateral R60.0 Lcalized edema R60.1 Generalized edema R60.9 Edema, unspecified T80.0XXA Air emblism fllwing infusin, transfusin and therapeutic injectin, initial encunter T80.1XXA Vascular cmplicatins fllwing infusin, transfusin and therapeutic injectin, initial encunter 29

30 ICD-10 Cdes that DO NOT Supprt Medical Necessity Nte: Perfrmance T81.72XA Cmplicatin f vein fllwing a prcedure, nt elsewhere classified, initial encunter Z01.810* Encunter fr preprcedural cardivascular examinatin Z01.818* Encunter fr ther preprcedural examinatin Z09* Encunter fr fllw-up examinatin after cmpleted treatment fr cnditins ther than malignant neplasm Grup 1: Asterisk *NOTE: Use ICD-10-CM cde I74.9 t reprt paradxical emblism. *NOTE: ICD-10-CM cde Z is nly cvered fr CPT cde *NOTE: ICD-10-CM cde Z is cvered fr either CPT/HCPCS cde r G0365 nly (Refer t Grup 2 cdes fr HCPCS cde G0365). Please refer t Article A55529, Cding Guidelines: Nn-Invasive Peripheral Venus Studies, fr mre infrmatin n reprting these cdes. *NOTE: Use ICD-10-CM cde Z09 nly t describe a limited venus duplex (CPT cde 93971) perfrmed within 72 hurs f a saphenus vein ablatin prcedure (CPT cdes 36475, 36476, 36478, r 36479). Grup 2: Paragraph Medicare is establishing the fllwing limited cverage fr HCPCS cde G0365: Cvered fr: Grup 2: Cdes N18.4 Chrnic kidney disease, stage 4 (severe) N18.5 Chrnic kidney disease, stage 5 N18.6 End stage renal disease Z01.818* Encunter fr ther preprcedural examinatin Grup 2: Asterisk *NOTE: HCPCS cde G0365 reprted with ICD-10-CM cde Z requires a secndary diagnsis cde f N18.4, N18.5, r N18.6. ICD-10- CM cde Z is cvered fr either CPT/HCPCS cde r G0365 nly (Refer t Grup 1 cdes fr CPT cde 93971). Please refer t Article A55529, Cding Guidelines: Nn-Invasive Peripheral Venus Studies, fr mre infrmatin n reprting these cdes. Grup 1: Paragraph All thse nt listed under the ICD-10 Cdes that Supprt Medical Necessity sectin f this plicy. Grup 1: Cdes 30

31 is ptimized by using cde ranges. Additinal ICD-10 Infrmatin Assciated Dcuments Attachments Related Lcal Cverage Dcuments Related Natinal Cverage Dcuments There are n attachments fr this LCD. This LCD versin has n Related Lcal Cverage Dcuments. This LCD versin has n Related Natinal Cverage Dcuments. 31