Non-Invasive Peripheral Arterial Studies

Article Title

Non-Invasive Peripheral Arterial Studies – 4U-20AB-R7

Contractor’s Determination Number

4U-20AB

Contractor Name

TrailBlazer Health Enterprises

Contractor Number

04001 (04101, 04201, 04301, 04401, 04901).
04002 (04102, 04202, 04302, 04402).

Contractor Type

MAC – Part A.
MAC – Part B.

AMA CPT/ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply. Current Dental Terminology (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Indian Health Service.
End Stage Renal Disease (ESRD) facilities.
Skilled Nursing Facilities (SNFs).
Rural Health Clinics (RHCs).

Transitioned WPS legacy providers.

Oversight Region

Region IV.
Region VI.

Original Article Effective Date

03/01/2008

03/21/2008

06/13/2008

Article Revision Effective Date

01/01/2012

Article Ending Effective Date

N/A

Article Text

Abstract

Vascular ultrasound imaging technology records images of blood flow in the extremities via the use of sound waves. Plethysmography involves the measurement and recording of changes in the size of a body part as modified by the circulation of blood in that part. Physiologic studies include functional measurement procedures (Doppler ultrasound studies, blood pressure measurements and differentials, transcutaneous oxygen tension measurements or plethysmography). Non-invasive peripheral arterial disease studies are useful in detecting extremity arterial compromise, functional severity and hemodynamic significance of atherosclerosis. These procedures help in differentiating claudication from pain on non-vascular etiologies. Lower extremity testing is also a valuable tool in monitoring graft and other interventional procedural complications including occlusions, early flow compromise secondary to technical problems, or chronic recurrence of anastomotic or distal disease, and aneurysmal diseases of the artery. Information regarding collateral circulation can also be gained.

The LCD related to this article defines medically reasonable and necessary clinical circumstances in which Medicare will cover non-invasive peripheral arterial studies.

Part A Program Instructions:

Reasons for Denial

All other indications not listed in the “Indications and Limitations of Coverage” section of this LCD.
Service(s) rendered is (are) not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of this LCD.
The service is considered:

Investigational.
For routine screening.
Otherwise not covered.

“Non-specific leg pain” and “pain in limb” as single diagnoses are too general to warrant further investigation without documentation of other signs and symptoms.
If the only indication for non-invasive arterial studies is the absence of either or both dorsalis pedis and posterior tibial pulses in the absence of diabetes or other signs and/or symptoms of arterial insufficiency.
Non-invasive arterial studies are not medically necessary when edema is the only sign or symptom of peripheral vascular disease.
The following methods are not reimbursed under the HCPCS codes listed in this policy (i.e., 93922, 93923, 93924, 93925, 93926, 93930 and 93931):

Mechanical oscillometry.
Inductance plethysmography.
Capitance plethysmography.
Photoelectric plethysmography.
Ankle/Brachial Indices (ABI) (considered part of the physical examination).

Intraoperative arterial studies that are regarded as an integral and necessary part of an operative procedure are not separately reimbursable.
The use of contrast media, i.e., microbubbles, with non-invasive peripheral arterial studies is considered investigational and is therefore not covered.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.
To report these services, use the appropriate CPT/HCPCS code(s).
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
The diagnosis code(s) must be representative of the patient’s condition.
All coverage criteria must be met before Medicare can reimburse this service.
For duplex scan for post-interventional follow-up, which is typically limited in scope and unilateral in nature, use the unilateral (or limited study) code 93926 or 93931. Consequently, the complete duplex scan code 93925 or 93930 should seldom be used, except in patients who had bilateral interventions.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.)

See also Bill Type and Revenue Code sections below.

Part B Program Instructions:

Reasons for Denial

All other indications not listed in the “Indications and Limitations of Coverage” section of this LCD.
Service(s) rendered is (are) not consistent with accepted standards of medical practice.
The medical record does not verify that the service described by the CPT/HCPCS code was provided.
The service does not follow the guidelines of this LCD.
The service is considered:

Investigational.
For routine screening.
Otherwise not covered.

“Non-specific leg pain” and “pain in limb” as single diagnoses are too general to warrant further investigation without documentation of other signs and symptoms.
If the only indication for non-invasive arterial studies is the absence of either or both dorsalis pedis and posterior tibial pulses in the absence of diabetes or other signs and/or symptoms of arterial insufficiency.
Non-invasive arterial studies are not medically necessary when edema is the only sign or symptom of peripheral vascular disease.
The following methods are not reimbursed under the HCPCS codes listed in this policy (i.e., 93922, 93923, 93924, 93925, 93926, 93930 and 93931):

Mechanical oscillometry.
Inductance plethysmography.
Capitance plethysmography.
Photoelectric plethysmography.
Ankle/Brachial Indices (ABI) (considered part of the physical examination).

Intraoperative arterial studies that are regarded as an integral and necessary part of an operative procedure are not separately reimbursable.
The use of contrast media, i.e., microbubbles, with non-invasive peripheral arterial studies is considered investigational and is therefore not covered.

Coding Guidelines

Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits.
To report these services, use the appropriate CPT/HCPCS code(s).
Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service.
The diagnosis code(s) must be representative of the patient’s condition.
All coverage criteria must be met before Medicare can reimburse this service.
For duplex scan for post-interventional follow-up, which is typically limited in scope and unilateral in nature, use the unilateral (or limited study) code 93926 or 93931. Consequently, the complete duplex scan code 93925 or 93930 should seldom be used, except in patients who had bilateral interventions.
When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.

Modifiers:

GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.)
GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.)

Bill Type and Revenue Codes below DO NOT apply to Part B.

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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 83X, 85X

Revenue Codes

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 policy 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 policy should be assumed to apply equally to all Revenue Codes.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all the Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.

092X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
93922©	Upr/l xtremity art 2 levels
93923©	Upr/lxtr art stdy 3+ lvls
93924©	Extremity study
93925©	Lower extremity study
93926©	Lower extremity study
93930©	Upper extremity study
93931©	Upper extremity study

Other Comments

N/A