LCD Title Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
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CMS National Coverage Policy
Italicized font represents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.
Title XVIII of the Social Security Act section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
Title XVIII of the Social Security Act section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act section 1862 (a) (1) (D) excludes Medicare payment for any expenses incurred for items or services that are investigational or experimental.
Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations and services from Medicare coverage.
42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiarys specific medical problem. Tests not ordered by the physician or other qualified non-physician provider who is treating the patient are not reasonable and necessary (see 42 CFR 411.15(k) (1).
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42 CFR, Section 410.32 (b) Diagnostic x-ray and other diagnostic tests. (1) Basic rule. .. all diagnostic x-ray and other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861® of the Act. Services furnished without the required level of supervision are not reasonable and necessary. (see 42 CFR 411.15(k)(1)).
CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 11 End Stage Renal Disease, Section 40 Other Services. Chapter 15 Covered Medical and Other Health Services, Section 80 Requirements for Diagnostic X-rays, Diagnostic Laboratory, and Other Diagnostic Tests.
CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 Coverage Determinations Part 1, Section 20.14 Plethysmography and Part 4, Sections 220.5 - Ultrasound Diagnostic Procedures,
CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 7 SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section 50 Billing Part B Radiology Services and Other Diagnostic Procedures; Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims, Sections 140 Monthly Capitation Payment Methods for Physicians Services furnished to Patients on Maintenance Dialysis. A. Services included in monthly Capitation Payment and 180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services; Chapter 13 Radiology Services and Other Diagnostic Procedures, Sections 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures and 20 Payment Conditions for Radiology Services; and Chapter 16 Laboratory Services, Section 40.2 Payment Limit for Purchased Services, and Chapter 23 Fee Schedule Administration and Coding Requirements, Addendum MPFSDB Record Layouts.
CMS Pub 100-08, Medicare Program Integrity Manual, Chapter 13 Local Coverage Determinations, Section 13.5.1 Reasonable and Necessary Provisions in LCDs.
CMS Publication 100-09, Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Overview Non-invasive peripheral venous vascular studies utilize ultrasonic Doppler and physiologic studies to assess the irregularities in blood flow in the venous system. Noninvasive peripheral venous vascular studies include the patient care required to perform the studies, supervision of the studies, and interpretation of study results, with copies for patient records of test results and analysis of all data, including bi-directional vascular flow or imaging when provided.
Diagnostic tests must be ordered by the physician who is treating the beneficiary and use the result in the management of the beneficiarys specific medical problem. Services are deemed medically necessary when
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1. Signs/symptoms of ischemia or altered blood flow are present;
2. The information is necessary for appropriate medical and/or surgical management;
3. The test is not redundant of other diagnostic procedures that must be performed.
Definitions: Duplex Scans: Duplex combines Doppler and conventional ultrasound, allowing the structure of blood vessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to be seen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds into colors overlaid on the image, representing information about the speed and direction of blood flow. Using spectral Doppler analysis, the duplex scan images provide anatomic and hemodynamic information, identifying the plaque, occlusions and incompetent veins. Duplex scans are in real-time.
Physiologic Studies: Functional measurement procedures which include Doppler ultrasound studies, blood pressure and physiologic waveforms, segmental pressure measurements, blood pressure measurements, transcutaneous oxygen tension measurements, exercise testing, and/or plethysmography. These studies do not involve imaging.
Doppler Ultrasound: Uses reflected sound waves called physiologic waveforms to evaluate the blood as it flows through a vein. The waveforms bounce off blood cells in a motion that causes a change in the pitch of the sound, called the Doppler effect. These can be measured at a single level, or a segmental (various) limb levels. An audible sound is created and recorded by either an analog recorder or spectral analyzer. Spectral analysis separates the signal into individual components and assigns a relative importance. If there is no blood flow, the pitch does not change. The receiver detects the shift.
Exercise testing can be used to analyze the functional significance of vascular disease by reassessing the blood pressure with the Doppler stethoscope after completion of an appropriate amount of stress testing.
Plethysmography is a measurement of the volume of an organ or limb section, or flow rate, in response to the inflation and deflation of a BP cuff. Volume measurement procedures include air, impedance or strain gauge methods.
I. Peripheral Venous Vascular Studies (93965, 93970, 93971) Indications for peripheral venous vascular examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies, which are medically necessary to determine subsequent treatment, are covered if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedures.
A. Deep Vein Thrombosis (DVT) Indications: The signs and symptoms of DVT are relatively non-specific; and due to the risk associated with pulmonary embolism (PE), objective testing is allowed in patients who are candidates for anticoagulation or invasive therapeutic procedures for the following conditions:
1. Clinical signs and/or symptoms of DVT including edema, tenderness, inflammation, and/or erythema.
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2. Clinical signs and/or symptoms of pulmonary embolism (PE) including hemoptysis, chest pain, and/or dyspnea.
3. Unexplained lower extremity edema status, post major surgical procedures, trauma, other or progressive illness/condition; surveillance following high-risk surgical procedures, such as orthopedic or pelvic. Individual consideration will be given to surveillance of patients on prolonged bed rest (e.g., due to neurologic, condition / procedures, congestive heart failure, and paradoxical emboli). In general, surveillance is not necessary when effective antithrombotic measures (e.g., anticoagulants, alternating pressure devices) are being used. However, it may be necessary in some patients prior to applying alternating pressure devices or compression dressings under appropriate clinical circumstances.
4. Unexplained lower extremity pain, excluding pain of skeletal origin.
5. Bilateral limb edema is rarely an indicator for medical necessity in the presence of signs and symptoms of heart failure, exogenous obesity, and/or arthritis.
B. Chronic Venous Insufficiency Indications: Chronic venous insufficiency may be divided into three categories: primary varicose veins, post-thrombotic (post-phlebitic) syndrome, and recurrent deep vein thrombosis. Peripheral vascular studies may be indicated in patients with:
1. Ulceration suspected to be secondary to venous insufficiency. These tests may be indicated to confirm this diagnosis by documenting venous valvular incompetence prior to invasive therapeutic treatment.
2. Varicose veins by themselves do not indicate medical necessity, but medical necessity may be indicated when they are accompanied by significant pain or stasis dermatitis. It is not medically necessary to study asymptomatic primary varicose veins (See WPS policy L34536, Treatment of Varicose Veins of the Lower Extremities).
3. Superficial thrombophlebitis involving the proximal thigh, to investigate whether there was thrombus at the saphenofemoral junction that would demand either anticoagulation or surgical ligation.
4. Evaluation is medically necessary in patients with symptoms of recurrent DVT or in patients prior to compression therapy to exclude superimposed acute DVT which may be at risk for embolization with such therapy.
C. Venous Mapping Indications: Vein mapping is considered medically reasonable and necessary when the patients clinical evaluation indicates one of the following:
1. Previous partial harvest of the vein.
2. Previous thrombophlebitis or DVT in the leg.
3. Severe varicose veins.
5. Obesity to the degree it interferes with clinical determination.
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6. Other indications must be clearly supported by medical documentation.
7. Vein mapping may be performed prior to creating a dialysis fistula. See section III in this policy on vessel mapping of vessels for hemodialysis.
8. Mapping the saphenous veins prior to scheduled revascularization procedures is covered when it is expected that an autologous vein will be used, but only if there is uncertainty regarding the availability of a suitable vein for bypass.
Limitations:
9. Vein mapping as a routine preoperative study is not covered.
10. Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study is indicated for the preoperative examination of potential harvest vein grafts to be utilized during bypass surgery. This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for the bypass surgery must be determined prior to the performance of the test.
II. Hemodialysis Access Studies (93990) Medicare considers a Doppler flow study medically necessary when the patients dialysis access site manifests signs or symptoms associated with vascular compromise, and when the results of this test are necessary to determine the clinical course of treatment.
Indications: Examples supporting the medical necessity for Doppler flow studies include:
1. Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,
2. Elevated recirculation of 12 percent or greater, and
3. An otherwise unexplained urea reduction ratio <60 percent, and
4. An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction).
(Medicare Benefit Policy Manual, Chapter 11-End Stage renal Disease (ESRD), Section 40, H.)
III. Vessel Mapping of Vessels for Hemodialysis Access (93970, 93971, 93990, G0365) Indications: Vessel mapping of vessels for hemodialysis access is considered for Medicare payment when it is performed preoperatively prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow in patients with end stage renal disease (ESRD). This is a covered service only when the results of the study are necessary to determine appropriate vessel utilization. The need for a hemodialysis access site must be determined prior to the performance of the test.
Limitations: Unless the documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram), but not both. An example
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of when both studies may be clinically necessary is when a Doppler flow study demonstrates:
1. Reduced flow (blood flow rate less than 800cc/min or
2. A decreased flow of 25 percent or greater from previous study) and
3. The physician requires an arteriogram to define the problem.
(Medicare Benefit Policy Manual, Chapter 11-End Stage renal Disease (ESRD), Section 40, H).
Credentialing and Accreditation Standards The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience. A vascular diagnostic study may be personally performed by a physician, a certified technologist, or in a certified vascular testing lab.
Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
4. All non-invasive vascular diagnostic studies must be performed meeting at least one of the following:
a. performed by a licensed qualified physician, or
b. performed by a technician who is certified in vascular technology, or
c. performed in facilities with laboratories accredited in vascular technology.
5. A licensed qualified physician for these services is defined as:
a. Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or
b. Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and
c. Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed.
6. Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body.
Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing Internationals Registered Vascular Specialist (RVS).
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Coding Information
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.
999x Not Applicable 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.
N/A CPT/HCPCS Codes
NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY)
93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY
93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY
93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW)
G0365
VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES FOR PREOPERATIVE VESSEL MAPPING PRIOR TO CREATION OF HEMODIALYSIS ACCESS USING AN AUTOGENOUS HEMODIALYSIS CONDUIT, INCLUDING ARTERIAL INFLOW AND VENOUS OUTFLOW)
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Group 1 Paragraph: Peripheral Venous Examinations (93965, 93970, and 93971)
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.
Group 1 Codes:
ICD-10 Codes Description
D68.51 Activated protein C resistance D68.52 Prothrombin gene mutation D68.59 Other primary thrombophilia D68.61 Antiphospholipid syndrome D68.62 Lupus anticoagulant syndrome D68.69 Other thrombophilia D75.81 Myelofibrosis D75.82 Heparin induced thrombocytopenia (HIT) D75.89 Other specified diseases of blood and blood-forming organs I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I27.82 Chronic pulmonary embolism I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral I80.211 Phlebitis and thrombophlebitis of right iliac vein I80.212 Phlebitis and thrombophlebitis of left iliac vein I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral I80.221 Phlebitis and thrombophlebitis of right popliteal vein I80.222 Phlebitis and thrombophlebitis of left popliteal vein I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral I80.231 Phlebitis and thrombophlebitis of right tibial vein I80.232 Phlebitis and thrombophlebitis of left tibial vein I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral
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I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.8 Phlebitis and thrombophlebitis of other sites I82.1 Thrombophlebitis migrans I82.210 Acute embolism and thrombosis of superior vena cava I82.211 Chronic embolism and thrombosis of superior vena cava I82.290 Acute embolism and thrombosis of other thoracic veins I82.291 Chronic embolism and thrombosis of other thoracic veins I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity I82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremity I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I82.411 Acute embolism and thrombosis of right femoral vein I82.412 Acute embolism and thrombosis of left femoral vein I82.413 Acute embolism and thrombosis of femoral vein, bilateral I82.421 Acute embolism and thrombosis of right iliac vein I82.422 Acute embolism and thrombosis of left iliac vein I82.423 Acute embolism and thrombosis of iliac vein, bilateral I82.431 Acute embolism and thrombosis of right popliteal vein I82.432 Acute embolism and thrombosis of left popliteal vein I82.433 Acute embolism and thrombosis of popliteal vein, bilateral I82.441 Acute embolism and thrombosis of right tibial vein I82.442 Acute embolism and thrombosis of left tibial vein I82.443 Acute embolism and thrombosis of tibial vein, bilateral I82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremity I82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremity I82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity I82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity I82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral I82.511 Chronic embolism and thrombosis of right femoral vein I82.512 Chronic embolism and thrombosis of left femoral vein I82.513 Chronic embolism and thrombosis of femoral vein, bilateral I82.521 Chronic embolism and thrombosis of right iliac vein I82.522 Chronic embolism and thrombosis of left iliac vein I82.523 Chronic embolism and thrombosis of iliac vein, bilateral I82.531 Chronic embolism and thrombosis of right popliteal vein I82.532 Chronic embolism and thrombosis of left popliteal vein I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral I82.541 Chronic embolism and thrombosis of right tibial vein I82.542 Chronic embolism and thrombosis of left tibial vein I82.543 Chronic embolism and thrombosis of tibial vein, bilateral I82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity I82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity I82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.611 Acute embolism and thrombosis of superficial veins of right upper extremity I82.612 Acute embolism and thrombosis of superficial veins of left upper extremity I82.613 Acute embolism and thrombosis of superficial veins of upper extremity, bilateral I82.621 Acute embolism and thrombosis of deep veins of right upper extremity I82.622 Acute embolism and thrombosis of deep veins of left upper extremity I82.623 Acute embolism and thrombosis of deep veins of upper extremity, bilateral
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I82.711 Chronic embolism and thrombosis of superficial veins of right upper extremity I82.712 Chronic embolism and thrombosis of superficial veins of left upper extremity I82.713 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral I82.721 Chronic embolism and thrombosis of deep veins of right upper extremity I82.722 Chronic embolism and thrombosis of deep veins of left upper extremity I82.723 Chronic embolism and thrombosis of deep veins of upper extremity, bilateral I82.811 Embolism and thrombosis of superficial veins of right lower extremities I82.812 Embolism and thrombosis of superficial veins of left lower extremities I82.813 Embolism and thrombosis of superficial veins of lower extremities, bilateral I82.890 Acute embolism and thrombosis of other specified veins I82.891 Chronic embolism and thrombosis of other specified veins I82.A11 Acute embolism and thrombosis of right axillary vein I82.A12 Acute embolism and thrombosis of left axillary vein I82.A13 Acute embolism and thrombosis of axillary vein, bilateral I82.A21 Chronic embolism and thrombosis of right axillary vein I82.A22 Chronic embolism and thrombosis of left axillary vein I82.A23 Chronic embolism and thrombosis of axillary vein, bilateral I82.B11 Acute embolism and thrombosis of right subclavian vein I82.B12 Acute embolism and thrombosis of left subclavian vein I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral I82.B21 Chronic embolism and thrombosis of right subclavian vein I82.B22 Chronic embolism and thrombosis of left subclavian vein I82.B23 Chronic embolism and thrombosis of subclavian vein, bilateral I82.C11 Acute embolism and thrombosis of right internal jugular vein I82.C12 Acute embolism and thrombosis of left internal jugular vein I82.C13 Acute embolism and thrombosis of internal jugular vein, bilateral I82.C21 Chronic embolism and thrombosis of right internal jugular vein I82.C22 Chronic embolism and thrombosis of left internal jugular vein I82.C23 Chronic embolism and thrombosis of internal jugular vein, bilateral I83.011 Varicose veins of right lower extremity with ulcer of thigh I83.012 Varicose veins of right lower extremity with ulcer of calf I83.013 Varicose veins of right lower extremity with ulcer of ankle I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015 Varicose veins of right lower extremity with ulcer other part of foot I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg I83.021 Varicose veins of left lower extremity with ulcer of thigh I83.022 Varicose veins of left lower extremity with ulcer of calf I83.023 Varicose veins of left lower extremity with ulcer of ankle I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025 Varicose veins of left lower extremity with ulcer other part of foot I83.028 Varicose veins of left lower extremity with ulcer other part of lower leg I83.11 Varicose veins of right lower extremity with inflammation I83.12 Varicose veins of left lower extremity with inflammation I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation
I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation
I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation
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I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation
I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation
I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation
I83.811 Varicose veins of right lower extremities with pain I83.812 Varicose veins of left lower extremities with pain I83.813 Varicose veins of bilateral lower extremities with pain I83.891 Varicose veins of right lower extremities with other complications I83.892 Varicose veins of left lower extremities with other complications I83.893 Varicose veins of bilateral lower extremities with other complications I83.91 Asymptomatic varicose veins of right lower extremity I83.92 Asymptomatic varicose veins of left lower extremity I83.93 Asymptomatic varicose veins of bilateral lower extremities I87.001 Postthrombotic syndrome without complications of right lower extremity I87.002 Postthrombotic syndrome without complications of left lower extremity I87.003 Postthrombotic syndrome without complications of bilateral lower extremity I87.011 Postthrombotic syndrome with ulcer of right lower extremity I87.012 Postthrombotic syndrome with ulcer of left lower extremity I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity I87.021 Postthrombotic syndrome with inflammation of right lower extremity I87.022 Postthrombotic syndrome with inflammation of left lower extremity I87.023 Postthrombotic syndrome with inflammation of bilateral lower extremity I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity I87.091 Postthrombotic syndrome with other complications of right lower extremity I87.092 Postthrombotic syndrome with other complications of left lower extremity I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity I87.1 Compression of vein I87.2 Venous insufficiency (chronic) (peripheral) I87.301 Chronic venous hypertension (idiopathic) without complications of right lower extremity I87.302 Chronic venous hypertension (idiopathic) without complications of left lower extremity
I87.303 Chronic venous hypertension (idiopathic) without complications of bilateral lower extremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity
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I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity
I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity
I87.8 Other specified disorders of veins I96 Gangrene, not elsewhere classified
I97.410 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac catheterization
I97.411 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac bypass
I97.418 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other circulatory system procedure
I97.42 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other procedure
I97.51 Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure
I97.52 Accidental puncture and laceration of a circulatory system organ or structure during other procedure
I97.610 Postprocedural hemorrhage of a circulatory system organ or structure following a cardiac catheterization
I97.611 Postprocedural hemorrhage of a circulatory system organ or structure following cardiac bypass
I97.618 Postprocedural hemorrhage of a circulatory system organ or structure following other circulatory system procedure
I97.620 Postprocedural hemorrhage of a circulatory system organ or structure following other procedure
I97.621 Postprocedural hematoma of a circulatory system organ or structure following other procedure
I97.622 Postprocedural seroma of a circulatory system organ or structure following other procedure
I97.630 Postprocedural hematoma of a circulatory system organ or structure following a cardiac catheterization
I97.631 Postprocedural hematoma of a circulatory system organ or structure following cardiac bypass
I97.638 Postprocedural hematoma of a circulatory system organ or structure following other circulatory system procedure
I97.640 Postprocedural seroma of a circulatory system organ or structure following a cardiac catheterization
I97.641 Postprocedural seroma of a circulatory system organ or structure following cardiac bypass
I97.648 Postprocedural seroma of a circulatory system organ or structure following other circulatory system procedure
J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia L53.8 Other specified erythematous conditions L53.9 Erythematous condition, unspecified L54 Erythema in diseases classified elsewhere
L76.01 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating a dermatologic procedure
L76.02 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating other procedure
L76.11 Accidental puncture and laceration of skin and subcutaneous tissue during a dermatologic procedure
L76.12 Accidental puncture and laceration of skin and subcutaneous tissue during other procedure
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L76.21 Postprocedural hemorrhage of skin and subcutaneous tissue following a dermatologic procedure
L76.22 Postprocedural hemorrhage of skin and subcutaneous tissue following other procedure L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed L97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscle L97.314 Non-pressure chronic ulcer of right ankle with necrosis of bone L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone L97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed L97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone L97.811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone
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M79.601 Pain in right arm M79.602 Pain in left arm M79.604 Pain in right leg M79.605 Pain in left leg M79.621 Pain in right upper arm M79.622 Pain in left upper arm M79.631 Pain in right forearm M79.632 Pain in left forearm M79.641 Pain in right hand M79.642 Pain in left hand M79.651 Pain in right thigh M79.652 Pain in left thigh M79.661 Pain in right lower leg M79.662 Pain in left lower leg M79.671 Pain in right foot M79.672 Pain in left foot M79.89 Other specified soft tissue disorders
M96.810 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating a musculoskeletal system procedure
M96.811 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating other procedure
M96.820 Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletal system procedure
M96.821 Accidental puncture and laceration of a musculoskeletal structure during other procedure
M96.830 Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletal system procedure
M96.831 Postprocedural hemorrhage of a musculoskeletal structure following other procedure O22.01 Varicose veins of lower extremity in pregnancy, first trimester O22.02 Varicose veins of lower extremity in pregnancy, second trimester O22.03 Varicose veins of lower extremity in pregnancy, third trimester O22.11 Genital varices in pregnancy, first trimester O22.12 Genital varices in pregnancy, second trimester O22.13 Genital varices in pregnancy, third trimester O22.21 Superficial thrombophlebitis in pregnancy, first trimester O22.22 Superficial thrombophlebitis in pregnancy, second trimester O22.23 Superficial thrombophlebitis in pregnancy, third trimester O22.31 Deep phlebothrombosis in pregnancy, first trimester O22.32 Deep phlebothrombosis in pregnancy, second trimester O22.33 Deep phlebothrombosis in pregnancy, third trimester O86.81 Puerperal septic thrombophlebitis O87.0 Superficial thrombophlebitis in the puerperium O87.4 Varicose veins of lower extremity in the puerperium Q27.31 Arteriovenous malformation of vessel of upper limb Q27.32 Arteriovenous malformation of vessel of lower limb Q27.39 Arteriovenous malformation, other site Q27.8 Other specified congenital malformations of peripheral vascular system R04.2 Hemoptysis R04.89 Hemorrhage from other sites in respiratory passages R06.00 Dyspnea, unspecified R06.02 Shortness of breath R07.1 Chest pain on breathing
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R07.89 Other chest pain R09.02 Hypoxemia R22.31 Localized swelling, mass and lump, right upper limb R22.32 Localized swelling, mass and lump, left upper limb R22.33 Localized swelling, mass and lump, upper limb, bilateral R22.41 Localized swelling, mass and lump, right lower limb R22.42 Localized swelling, mass and lump, left lower limb R22.43 Localized swelling, mass and lump, lower limb, bilateral R60.0 Localized edema S35.514A Injury of right iliac vein, initial encounter S35.515A Injury of left iliac vein, initial encounter S35.59XA Injury of other iliac blood vessels, initial encounter S45.211A Laceration of axillary or brachial vein, right side, initial encounter S45.212A Laceration of axillary or brachial vein, left side, initial encounter S45.291A Other specified injury of axillary or brachial vein, right side, initial encounter S45.292A Other specified injury of axillary or brachial vein, left side, initial encounter S45.311A Laceration of superficial vein at shoulder and upper arm level, right arm, initial encounter S45.312A Laceration of superficial vein at shoulder and upper arm level, left arm, initial encounter
S45.391A Other specified injury of superficial vein at shoulder and upper arm level, right arm, initial encounter
S45.392A Other specified injury of superficial vein at shoulder and upper arm level, left arm, initial encounter
S55.211A Laceration of vein at forearm level, right arm, initial encounter S55.212A Laceration of vein at forearm level, left arm, initial encounter S55.291A Other specified injury of vein at forearm level, right arm, initial encounter S55.292A Other specified injury of vein at forearm level, left arm, initial encounter S75.111A Minor laceration of femoral vein at hip and thigh level, right leg, initial encounter S75.112A Minor laceration of femoral vein at hip and thigh level, left leg, initial encounter S75.121A Major laceration of femoral vein at hip and thigh level, right leg, initial encounter S75.122A Major laceration of femoral vein at hip and thigh level, left leg, initial encounter S75.191A Other specified injury of femoral vein at hip and thigh level, right leg, initial encounter S75.192A Other specified injury of femoral vein at hip and thigh level, left leg, initial encounter S75.211A Minor laceration of greater saphenous vein at hip and thigh level, right leg, initial encounter S75.212A Minor laceration of greater saphenous vein at hip and thigh level, left leg, initial encounter S75.221A Major laceration of greater saphenous vein at hip and thigh level, right leg, initial encounter S75.222A Major laceration of greater saphenous vein at hip and thigh level, left leg, initial encounter
S75.291A Other specified injury of greater saphenous vein at hip and thigh level, right leg, initial encounter
S75.292A Other specified injury of greater saphenous vein at hip and thigh level, left leg, initial encounter
S85.311A Laceration of greater saphenous vein at lower leg level, right leg, initial encounter S85.312A Laceration of greater saphenous vein at lower leg level, left leg, initial encounter
S85.391A Other specified injury of greater saphenous vein at lower leg level, right leg, initial encounter
S85.392A Other specified injury of greater saphenous vein at lower leg level, left leg, initial encounter S85.411A Laceration of lesser saphenous vein at lower leg level, right leg, initial encounter S85.412A Laceration of lesser saphenous vein at lower leg level, left leg, initial encounter S85.491A Other specified injury of lesser saphenous vein at lower leg level, right leg, initial encounter S85.492A Other specified injury of lesser saphenous vein at lower leg level, left leg, initial encounter S85.511A Laceration of popliteal vein, right leg, initial encounter S85.512A Laceration of popliteal vein, left leg, initial encounter
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S85.591A Other specified injury of popliteal vein, right leg, initial encounter S85.592A Other specified injury of popliteal vein, left leg, initial encounter S95.211A Laceration of dorsal vein of right foot, initial encounter S95.212A Laceration of dorsal vein of left foot, initial encounter S95.291A Other specified injury of dorsal vein of right foot, initial encounter S95.292A Other specified injury of dorsal vein of left foot, initial encounter T38.4X5A Adverse effect of oral contraceptives, initial encounter T38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
T45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initial encounter
T79.0XXAAir embolism (traumatic), initial encounter T79.1XXAFat embolism (traumatic), initial encounter T79.A11A Traumatic compartment syndrome of right upper extremity, initial encounter T79.A12A Traumatic compartment syndrome of left upper extremity, initial encounter T79.A21A Traumatic compartment syndrome of right lower extremity, initial encounter T79.A22A Traumatic compartment syndrome of left lower extremity, initial encounter T79.A3XATraumatic compartment syndrome of abdomen, initial encounter T79.A9XATraumatic compartment syndrome of other sites, initial encounter T80.0XXAAir embolism following infusion, transfusion and therapeutic injection, initial encounter
T80.1XXAVascular complications following infusion, transfusion and therapeutic injection, initial encounter
T80.810A Extravasation of vesicant antineoplastic chemotherapy, initial encounter T80.818A Extravasation of other vesicant agent, initial encounter
T80.89XA Other complications following infusion, transfusion and therapeutic injection, initial encounter
T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter
T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounter T81.33XA Disruption of traumatic injury wound repair, initial encounter T81.4XXAInfection following a procedure, initial encounter T82.318A Breakdown (mechanical) of other vascular grafts, initial encounter T82.328A Displacement of other vascular grafts, initial encounter T82.338A Leakage of other vascular grafts, initial encounter T82.398A Other mechanical complication of other vascular grafts, initial encounter T82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial encounter T82.42XA Displacement of vascular dialysis catheter, initial encounter T82.43XA Leakage of vascular dialysis catheter, initial encounter T82.49XA Other complication of vascular dialysis catheter, initial encounter T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter T82.520A Displacement of surgically created arteriovenous fistula, initial encounter T82.521A Displacement of surgically created arteriovenous shunt, initial encounter T82.523A Displacement of balloon (counterpulsation) device, initial encounter T82.524A Displacement of infusion catheter, initial encounter T82.525A Displacement of umbrella device, initial encounter T82.528A Displacement of other cardiac and vascular devices and implants, initial encounter T82.530A Leakage of surgically created arteriovenous fistula, initial encounter T82.531A Leakage of surgically created arteriovenous shunt, initial encounter T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter
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T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter T85.818A Embolism due to other internal prosthetic devices, implants and grafts, initial encounter T85.868A Thrombosis due to other internal prosthetic devices, implants and grafts, initial encounter
T85.898A Other specified complication of other internal prosthetic devices, implants and grafts, initial encounter
Z01.818 Encounter for other preprocedural examination
Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm
Z86.711 Personal history of pulmonary embolism Z86.718 Personal history of other venous thrombosis and embolism Z86.72 Personal history of thrombophlebitis Z86.74 Personal history of sudden cardiac arrest
Group 2 Paragraph: Hemodialysis Access Examination (93990)
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.
Group 2 Codes:
ICD-10 Codes Description
T82.7XXAInfection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
Z99.2 Dependence on renal dialysis
Group 3 Paragraph: Vessel Mapping for Vessels for Hemodialysis Access (G0365)
Pre-operative examination for potential harvest vein grafts or pre-operative examination of vessel prior to
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hemodialysis access surgery Z01.818.
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.
Group 3 Codes:
ICD-10 Codes Description
I74.2 Embolism and thrombosis of arteries of the upper extremities N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease T82.42XA Displacement of vascular dialysis catheter, initial encounter T82.43XA Leakage of vascular dialysis catheter, initial encounter T82.49XA Other complication of vascular dialysis catheter, initial encounter T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter T82.520A Displacement of surgically created arteriovenous fistula, initial encounter T82.530A Leakage of surgically created arteriovenous fistula, initial encounter T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter
T82.7XXAInfection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter T82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounter T82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounter T82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounter T82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter
Z01.818 Encounter for other preprocedural examination
ICD-10 Codes that DO NOT Support Medical Necessity
Group 1 Paragraph: N/A
Group 1 Codes: N/A
General Information
Associated Information
Documentation Requirements Adequate documentation is essential for high-quality patient care and to demonstrate the reasonableness and medical necessity of the study(ies). Documentation must support the criteria as described in the Coverage Indications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent record of the performed studies and interpretation. The documentation should include a description of the studies performed and any contrast media and/or radiopharmaceuticals used. Any known significant patient reaction or complications should be recorded. Comparison with prior relevant studies needs to be addressed in the documentation along with both normal and abnormal findings. Variations from normal should be documented along with measurements. The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical questions, this should be explained in the documentation. Retention of the ultrasound examination images should be consistent both with clinical need and with relevant legal and local health care facility requirements.
If the provider of the study 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 practitioners order for the studies. This order is required to provide adequate diagnostic information to the performing provider. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her order for the test. The provider is responsible for ensuring the medical necessity of procedures and maintaining the medical record, which must be available to Medicare upon request. Results of all testing must be shared with the referring physician. Non-invasive vascular studies are medically reasonable and medically necessary only if the outcomes will be utilized in the clinical management of the patient.
Utilization Guidelines Each patients condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each study reported to be clearly documented in the patients medical record.
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 patients medical record.
Generally, it is expected that noninvasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services.
Only one preoperative scan is considered reasonable and necessary for hemodialysis access site surgery. If a more current preoperative scan is indicated for a patient with multiple comorbidities having difficulty being stabilized for surgery or a change in condition, the medical record would need to support the medical necessity of the second scan.
Only one limited study is considered reasonable and necessary post operatively within 72 hours of a saphenous vein ablation, whether surgery is performed on one side or bilaterally.
Pre-surgical conduit mapping of the radial artery(ies) should only be accompanied by vein-mapping studies when the arterial studies demonstrate a non-acceptable conduit or an insufficient conduit is available for multiple bypass procedures.
Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic
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studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support the medical necessity.
Documentation must be provided supporting the need for more than one imaging study Doppler flow or vessel mapping and arteriogram.
Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins during the same encounter is not appropriate as a general practice or standing protocol, and therefore, generally would not be expected to be done together. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter.
Preventive and/or screening services unless covered in Statute are not covered by Medicare. Sources of Information and Basis for Decision
ACR. (2010, Amended 2014). ACR-AIUM-SRU Practice parameter for the performance of peripheral venous ultrasound exam. American College of Radiology Practice Parameter. Resolution 39. pp.1-8.
ACR. (2011, Amended 2014). ACR-AIUM-SRU Practice parameter for the performance of ultrasound vascular mapping for the preoperative planning of dialysis access. American College of Radiology Practice Parameter. Resolution 39. pp.1-7.
ACR. (2011, Amended 2014). ACR-SPR-SRU Practice parameter for performing and interpreting diagnostic ultrasound examinations. American College of Radiology. Resolution 39. pp.1-6.
ACR. (Revised 2014). ACR Practice parameter for communication of diagnostic imaging findings. American College of Radiology Practice Parameter. Resolution 11. pp.1-9.
ACR. (Revised 2011). ACR Technical standard for diagnostic medical physics performance monitoring of real time ultrasound equipment. American College of Radiology Practice Parameter. Resolution 3. pp.1-7.
ACR. (2010, Sep 9). Ultrasound accreditation program requirements. American College of Radiology. pp.1-10.
Allon, J., Lockhart, M.E., Lilly, R.Z., & et al. (2001). Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney International, 60:2013-2020.
Erickson, C.A., & et al. (1996, Jan). Ongoing vascular laboratory surveillance is essential to maximize long-term in situ saphenous vein bypass patency. Journal of Vascular Surgery. 23(1):18-27.
Ferring, M., Henderson, J., Wilmink, A., & Smith, S. (2008). Vascular ultrasound for the pre-operative evaluation prior to arteriovenous fistula formation for hemodialysis: Review of the evidence. Nephrology Dialysis Transplantation, 23(6):1809-1815.
Gerhard-Herman, M., Gardin, JM., Jaff, M., Mohler, E., Roman, M., & Naqvi, T.Z. (2006, Aug). Guidelines for noninvasive laboratory testing: A report from the American Society of Echocardiography and the Society of Vascular Medicine and Biology. Journal of the American Society of Echocardiography. 19(8):955-972.
Intersocietal Accreditation Commission. (2013, Jun 15). IAC Standards and Guidelines for Vascular Testing Accreditation. Page 1-67.
National Kidney Foundation (2006). KDOQI clinical practice guidelines and recommendations: hemodialysis
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adequacy, peritoneal dialysis adequacy, vascular access.
Silva, M. B., Hobson, R. W., Pappas, P. J., & et al. (1997, Jun). A strategy for increasing use of autogenous hemodialysis access procedure: Impact of preoperative noninvasive evaluation. Journal of Vascular Surgery, 27(2):302-308.
Teodorescu, V., Gustavson, S., & Schanzer, H. (2012, Jun). Duplex ultrasound evaluation of hemodialysis access: A detailed protocol. International Journal of Nephrology. 2012(article no. 508956):1-7.
Revision History Information
10/01/2016R5
10/01/2016 ICD-10-CM code updates. Group 1 added codes: I97.620, I97.621, I97.622, I97.630, I97.631, I97.638, I97.640, I97.641, I97.648, T85.818A, T85.868A and T85.898A. Description changed codes: I97.610, I97.611, I97.618, L76.21, L76.22, M96.830, M96.831, T82.817A, T82.818A, T82.858A, T8.2867A and T82.868A. Deleted codes: I97.62, T85.81XA and T85.86XA. Group 2 Description changed codes: T82.818A, T82.828A, T82.838A, T82.848A, T82.858A and T82.868A. Group 3 Description changed codes: T82.818A, T82.828A, T82.838A, T82.848A, T82.858A and T82.868A. Added DNV-GL to the list of accrediting bodies.
Revisions Due To ICD-10-CM Code Changes
10/01/2015R4
Other (Annual Review)
10/01/2015R3 04/01/2016 Added R06.00 to Group 1 Codes effective 10/01/2015.
Other (Other Added ICD-10 codes)
Revisions Due To ICD-10-CM Code Changes
10/01/2015R2 01/01/2016 Added I80.201, I80.202, I80.203, I82.401, I82.402, I82.403, I82.501, I82.502, I82.503, and Z09 to Group 1 Codes effective 10/01/2015.
Other (Other Added ICD-10 codes)
10/01/2015R1 12/01/2015 Added the following codes to Group 1 Codes effective 10/01/2015: L53.8, L53.9, L54 and M79.89. Added the following statement to Group 1 Paragraph to clarify the codes with a 7th digit of A, D, or S: For codes in the table below that
Other (Added ICD-10 codes)
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require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used. All 7th digits listed in the Group 1 Codes table are now A with the ability to use D or S when coding the diagnosis. Removed the CAC information.
Revisions Due To ICD-10-CM Code Changes
Associated Documents
Article(s)
LCD(s)
L34536 - Treatment of Varicose Veins of the Lower Extremities Related National Coverage Documents
NCD(s)
Updated on 09/19/2016 with effective dates 10/01/2016 - N/A
Article Title Response to Comments: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
Article Type Response to Comments
AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2016 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
The Code on Dental Procedures and Nomenclature (Code) is published in Current
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Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.
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.
Article Guidance
Article Text:
This article summarizes the comments WPS received for Draft Local Coverage Determinations (LCD) Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (DL35751). Thank you for the comments.
Response to Comments
Response to Comments
Comment Response Comments received stating that if the studies are performed in the preoperative or pre-procedural setting, both physiologic studies and duplex scanning should be allowed at the same time as this facilitates assessment of the adequacy of revascularization and serves as a baseline for postoperative and post-procedural evaluation. These are often complimentary and not redundant studies. Some of the patients come to us with studies and we are unaware of the quality of them so we repeat all tests that are sent to us since we are making critical decisions affecting the patients health from medical assessment, imaging or surgery.
All testing covered by Medicare must be medically reasonable and necessary. Documentation must demonstrate why there was a need for repeat testing or additional testing.
Podiatrists asked if a podiatrist chooses to only perform the technical (TC) and not the professional component (26), does this LCD qualifying criteria apply to the physician
Whether doing the TC or PC, physicians would need to meet the criteria for qualification listed in the policy. The physician performing the technical component would use the modifier TC and
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performing the technical component independent or to the MD/DO vascular specialist interpreting the evaluation data and making/confirming the diagnosis?
physician interpreting the results would bill using modifier 26 for professional services.
Comments received expressing concerns that there are surveillance protocols for patients post-operatively, that has been shown in the literature, to improve bypass graft patency rates and should be covered without symptoms of ischemia.
Language and CPT codes were added to the policy to allow post-operative surveillance to be completed provided that there is documentation to support the medical necessity of ordering the studies.
Suggestions were made to make changes to Credentialing and Accreditation Standards or eliminate them altogether. While others expressed the need for stricter requirements and enforcement due to potential adverse outcomes that could result from inappropriately performed or interpreted studies.
Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.
1. All non-invasive vascular diagnostic studies must be performed meeting at least one of the following:
a. performed by a licensed qualified physician, or
b. performed by a technician who is certified in vascular technology, or
c. performed in facilities with laboratories accredited in vascular technology.
2. A licensed qualified physician for these services is defined as:
a. Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or
b. Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and
c. Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed.
3. Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as
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evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body. Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing Internationals Registered Vascular Specialist (RVS).
4. Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) Vascular Ultrasound Program, or Joint Commission must follow the accrediting bodys standards.
Podiatrists wrote that requiring a physician to have staff privileges to interpret vascular laboratory studies in a hospital or working in a certified vascular lab is neither a standard nor universally required within states or by vascular organizations, associations, or societies
It is not the intent of WPS to restrict the podiatric scope of practice. WPS uses Medicares definition of physicians which includes doctors of podiatric medicine. (CMS Pub 100-01 Medicare General Information, Eligibility, and Entitlement, Chapter 5 Definitions, Section 70.3 Doctors of Podiatric Medicine.) The section of the policy on credentialing and accreditation standards has been revised.
Comments were received that the proposed requirement that certified technologists directly supervise and review the work of noncertified technologists as problematic.
We agree that the Medicare regulations do describe the requirements for physician supervision and defines general, direct, and personal supervision. We have removed this statement since the ultimate responsibility for supervision and the quality of images is with the physician.
The LCDs indicate, it is recommended that noninvasive vascular studies either be rendered in a physicians office by/or under the direct supervision of persons credentialed in the specific type of procedure performed or performed in laboratories accredited in the specific type of evaluation. The Medicare physician fee schedule identifies the services in these LCDs as requiring general supervision, not direct. Any suggestion that direct supervision of these services is required should be removed from the LCDs such that they are compatible with national policy.
We have removed this language.
Comments were received that stated that Intersocietal Commission for Accreditation of Vascular Laboratories (ICAVL) is now the Intersocietal Accreditation Commission (IAC). The ARRT represents a radiologic credentialing body (The American Registry of
Thank you. We have corrected Intersocietal Accreditation Commission (IAC) throughout the policy. We have added American College of Radiology (ACR) to the list of credentialing boards. We removed the types of credentialing for individuals that each organization offers.
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Radiologic Technologists. Absent from this list is the American College of Radiology (ACR). ACR technologist certification should be added to this list. The ACC supports participation in physician certification and/or laboratory accreditation programs. Exceptions to mandates may be necessary to ensure that patients have access in underserved areas. We are concerned the proposed LCDs do not give a timeframe for requiring accreditation. We request that you allow groups a three year period within which they would become accredited.
Credentialing is not a new requirement. It was in the previous LCD (L28586), Non-Invasive Vascular Testing (NIVT), which was originally effective 05/18/2009.
Comments were received that there is a lack of policing the quality of the technicians and equipment with leads to repeating tests. Vascular labs should be required to be certified rather than what is currently in the policy that states the labs may be certified. That would take care of the technician requirements.
The LCD outlines the requirements for these procedures. Documentation of credentialing and qualifications of staff could be reviewed on a post pay basis.
Comments were received regarding routine venous mapping prior to bypass graft surgery not being covered. Commenters stated that it has been shown to reduce complications and facilitate earlier discharge.
All testing covered by Medicare must be medically reasonable and necessary. Documentation must demonstrate why there was a need for additional testing.
A comment was received that each draft LCD makes reference to documentation standards. While generally appropriate, some of the standards quoted from an American College of Radiology practice parameter would be overly proscriptive if applied universally. That practice parameter clearly states it would be inappropriate to take standards from an educational tool and apply them as inflexible rules or requirements of practice. The detailed, numbered documentation requirements should be deleted.
We agree and the four detailed, numbered parameters from ACR have been removed. This also removed the references to arterial segments.
Comment received that in the Utilization Guidelines only one preoperative scan is considered reasonable and necessary for bypass surgery, yet sometimes a second non-invasive vascular ultrasound is ordered rather than a CTA or MRA which are more expensive. If the operative planning is occurring in a tight time frame then only one scan might make sense. But when you are dealing with patients with lots of comorbidities and trying to get them stable and ready for surgery the data would be old and you need to repeat a scan. Another physician states that the literature does not speak to an interval when it would be appropriate to repeat the studies but it is based more on whether or not there is a change in patient symptoms that would
The following has been added to Utilization Guidelines: Only one preoperative scan is considered reasonable and necessary for bypass surgery. If a more current preoperative scan is indicated for a patient with multiple comorbidities having difficulty being stabilized for surgery or a change in condition, the medical record would need to support the medical necessity of the second scan.
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necessitate a reinvestigation.
The statement that duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease is problematic. Using the word may indicates that judgment will be used. If a group meets the criteria you have established, they should be reimbursed. We urge you to change the word.
WPS has added the following paragraph to Utilization Guidelines: Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support the medical necessity. The word may will continue to be used, because if it is determined to not be medically necessity or the documentation does not support medical necessity, the studies would be denied.
Received a statement that the policy states, generally, it is expected that noninvasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services. Comments noted that this was not true of an AVF (arteriovenous fistula) that has maturation procedures, and is being followed to assess improvement vs. need for further intervention.
All testing covered by Medicare must be medically reasonable and necessary. Documentation must demonstrate why there was a need for repeat testing or additional testing.
Only licensed MDs or DOs are allowed to sit for the ARDMS RPVT examination, this functionally barring all other individuals with licenses to practice medicine from sitting for the examination.
Medicare does not set the requirements for organizations that provide certifications for physicians and technicians.
Comment received that nephrology and vascular access labs were not mentioned in the credentialing and accreditation section of the policy.
None of the medical specialties were discussed in this section. The physician must been the requirements of a licensed qualified physician and the vascular lab must be accredited by one the accrediting bodies recognized by CMS.
Comments were received regarding information written in italics in the policy.
This italic information is taken directly out of the CMS Publication Manuals. WPS is not able to change how this information is written.
Writer request that the following ICD 10 codes be added to match the ICD 9 codes that are present. V12.51 Personal History of Venous Thrombosis and Embolism- ICD 10 Z86.718 V12.52 Personal History of Thrombophlebitis- ICD 10 Z86.72 V12.55 Personal History of Pulmonary Embolism- ICD 10 Z86.711 V67.09 Follow up examination other surgery- ICD 10 Z08 and Z09
Diagnostic codes Z86.711. Z86.718 and Z86.72 are already the ICD 10 policy L35751. Z08 and Z09 will not be added to the policy since they are encounters for follow-up examination after completed treatment for malignant neoplasm and for conditions other than malignant neoplasm.
Related Local Coverage Document(s)
NCD(s)
Public Version(s)
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Policy2233979.htm