UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL,
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LCD Title Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies 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 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. 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 beneficiary s 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). 1
Transcript of UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL,
LCD TitleNon-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies
AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT only copyright 2002-2016 American Medical Association. All RightsReserved. CPT is a registered trademark of the American MedicalAssociation. Applicable FARS/DFARS Apply to Government Use. Feeschedules, relative value units, conversion factors and/or related componentsare not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practicemedicine or dispense medical services. The AMA assumes no liability for datacontained or not contained herein.
The Code on Dental Procedures and Nomenclature (Code) is published inCurrent Dental Terminology (CDT). Copyright © American DentalAssociation. All rights reserved. CDT and CDT-2016 are trademarks of theAmerican 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 priorexpress, written consent of AHA.� Health Forum reserves the right to changethe copyright notice from time to time upon written notice to Company.
CMS National Coverage Policy
Italicized font represents CMS national NCD language/wording copied directly from CMS Manuals or CMSTransmittals. 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 lacksthe 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 orservices that are considered to be medically reasonable and necessary for the diagnosis or treatment of illnessor 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 expensesincurred for items or services that are investigational or experimental.
Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations andservices from Medicare coverage.
42 CFR, Section 410.32 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic indicates thatdiagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within thescope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary fora specific medical problem and who uses the results in the management of the beneficiary�s specific medicalproblem. Tests not ordered by the physician or other qualified non-physician provider who is treating thepatient 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-rayand other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician feeschedule must be furnished under the appropriate level of supervision by a physician as defined in section1861® of the Act. Services furnished without the required level of supervision are not reasonable andnecessary. (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, Section80 � Requirements for Diagnostic X-rays, Diagnostic Laboratory, and Other Diagnostic Tests.
CMS Pub 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 � CoverageDeterminations Part 1, Section20.14 � Plethysmography andPart 4, Sections 220.5 - Ultrasound Diagnostic Procedures,
CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 7 � SNF Part B Billing (Including InpatientPart B and Outpatient Fee Schedule), Section50 � 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 MaintenanceDialysis. A. � Services included in monthly Capitation Payment and180 - 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 and20 � Payment Conditions for Radiology Services; andChapter 16 � Laboratory Services, Section40.2 � Payment Limit for Purchased Services, andChapter 23 � Fee Schedule Administration and Coding Requirements, Addendum � MPFSDB RecordLayouts.
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
OverviewNon-invasive peripheral venous vascular studies utilize ultrasonic Doppler and physiologic studies to assessthe irregularities in blood flow in the venous system. Noninvasive peripheral venous vascular studies includethe 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 orimaging when provided.
Diagnostic tests must be ordered by the physician who is treating the beneficiary and use the result in themanagement of the beneficiary�s specific medical problem. Services are deemed medically necessary when
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all of the following conditions are met:
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 bloodvessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to beseen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds intocolors overlaid on the image, representing information about the speed and direction of blood flow. Usingspectral 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, bloodpressure and physiologic waveforms, segmental pressure measurements, blood pressure measurements,transcutaneous oxygen tension measurements, exercise testing, and/or plethysmography. These studies do notinvolve imaging.
Doppler Ultrasound: Uses reflected sound waves called physiologic waveforms to evaluate the blood as itflows through a vein. The waveforms bounce off blood cells in a motion that causes a change in the pitch ofthe sound, called the Doppler effect. These can be measured at a single level, or a segmental (various) limblevels. An audible sound is created and recorded by either an analog recorder or spectral analyzer. Spectralanalysis separates the signal into individual components and assigns a relative importance. If there is no bloodflow, 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 bloodpressure 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 theinflation and deflation of a BP cuff. Volume measurement procedures include air, impedance or strain gaugemethods.
I. Peripheral Venous Vascular Studies (93965, 93970, 93971)Indications for peripheral venous vascular examinations are separated into three major categories: deep veinthrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies, which are medically necessaryto determine subsequent treatment, are covered if the patient is a candidate for anticoagulation, thrombolysisor 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 pulmonaryembolism (PE), objective testing is allowed in patients who are candidates for anticoagulation or invasivetherapeutic 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/ordyspnea.
3. Unexplained lower extremity edema status, post major surgical procedures, trauma, other or progressiveillness/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 toneurologic, condition / procedures, congestive heart failure, and paradoxical emboli). In general, surveillanceis 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 devicesor 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 symptomsof heart failure, exogenous obesity, and/or arthritis.
B. Chronic Venous InsufficiencyIndications: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 indicatedin patients with:
1. Ulceration suspected to be secondary to venous insufficiency. These tests may be indicated to confirmthis 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 indicatedwhen they are accompanied by significant pain or stasis dermatitis. It is not medically necessary to studyasymptomatic primary varicose veins (See WPS policy L34536, Treatment of Varicose Veins of the LowerExtremities).
3. Superficial thrombophlebitis involving the proximal thigh, to investigate whether there was thrombus atthe 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 tocompression therapy to exclude superimposed acute DVT which may be at risk for embolization with suchtherapy.
C. Venous MappingIndications:Vein mapping is considered medically reasonable and necessary when the patient�s clinical evaluationindicates one of the following:
1. Previous partial harvest of the vein.
2. Previous thrombophlebitis or DVT in the leg.
3. Severe varicose veins.
4. Previous history of vein stripping, ligation, or sclerotherapy.
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 onvessel mapping of vessels for hemodialysis.
8. Mapping the saphenous veins prior to scheduled revascularization procedures is covered when it isexpected that an autologous vein will be used, but only if there is uncertainty regarding the availability of asuitable 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 orlimited study is indicated for the preoperative examination of potential harvest vein grafts to be utilized duringbypass surgery. This is a covered service only when the results of the study are necessary to locate suitablegraft 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 patient�s dialysis access sitemanifests signs or symptoms associated with vascular compromise, and when the results of this test arenecessary 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 seton 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 outflowobstruction).
(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 performedpreoperatively prior to creation of hemodialysis access using an autogenous hemodialysis conduit, includingarterial inflow and venous outflow in patients with end stage renal disease (ESRD). This is a covered serviceonly when the results of the study are necessary to determine appropriate vessel utilization. The need for ahemodialysis 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 limitpayment 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 StandardsThe accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience ofthe technologist and interpreter. Consequently, the physician performing and/or interpreting the study must becapable of demonstrating documented training and experience. A vascular diagnostic study may be personallyperformed 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 trainedproviders.
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 fellowshipprogram 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 applicablespecialty/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 ofdiagnostic procedure performed.
6. Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests andhave training and proficiency as evidenced by licensure or certification by an appropriate State health oreducation department. In the absence of a State licensing board, non-physician personnel must be certified byan appropriate national credentialing body.
Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers(ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular CredentialingInternational�s Registered Vascular Specialist (RVS).
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7. Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College ofRadiology (ACR) Vascular Ultrasound Program, Joint Commission or DNV-GL must follow the accreditingbody�s standards.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report thisservice. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Completeabsence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should beassumed to apply equally to all claims.
999x Not ApplicableRevenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used toreport 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. Completeabsence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policyshould be assumed to apply equally to all Revenue Codes.
N/ACPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
93965
NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETEBILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TOCOMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCEPLETHYSMOGRAPHY)
93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSIONAND OTHER MANEUVERS; COMPLETE BILATERAL STUDY
93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSIONAND 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 FORPREOPERATIVE VESSEL MAPPING PRIOR TO CREATION OF HEMODIALYSISACCESS USING AN AUTOGENOUS HEMODIALYSIS CONDUIT, INCLUDINGARTERIAL INFLOW AND VENOUS OUTFLOW)
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ICD-10 Codes that Support Medical Necessity
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 subsequentencounter or S sequela may be used.
Group 1 Codes:
ICD-10Codes Description
D68.51 Activated protein C resistanceD68.52 Prothrombin gene mutationD68.59 Other primary thrombophiliaD68.61 Antiphospholipid syndromeD68.62 Lupus anticoagulant syndromeD68.69 Other thrombophiliaD75.81 MyelofibrosisD75.82 Heparin induced thrombocytopenia (HIT)D75.89 Other specified diseases of blood and blood-forming organsI26.01 Septic pulmonary embolism with acute cor pulmonaleI26.02 Saddle embolus of pulmonary artery with acute cor pulmonaleI26.09 Other pulmonary embolism with acute cor pulmonaleI26.90 Septic pulmonary embolism without acute cor pulmonaleI26.92 Saddle embolus of pulmonary artery without acute cor pulmonaleI26.99 Other pulmonary embolism without acute cor pulmonaleI27.82 Chronic pulmonary embolismI80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremityI80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremityI80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateralI80.11 Phlebitis and thrombophlebitis of right femoral veinI80.12 Phlebitis and thrombophlebitis of left femoral veinI80.13 Phlebitis and thrombophlebitis of femoral vein, bilateralI80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremityI80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremityI80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateralI80.211 Phlebitis and thrombophlebitis of right iliac veinI80.212 Phlebitis and thrombophlebitis of left iliac veinI80.213 Phlebitis and thrombophlebitis of iliac vein, bilateralI80.221 Phlebitis and thrombophlebitis of right popliteal veinI80.222 Phlebitis and thrombophlebitis of left popliteal veinI80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateralI80.231 Phlebitis and thrombophlebitis of right tibial veinI80.232 Phlebitis and thrombophlebitis of left tibial veinI80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral
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I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremityI80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremityI80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateralI80.8 Phlebitis and thrombophlebitis of other sitesI82.1 Thrombophlebitis migransI82.210 Acute embolism and thrombosis of superior vena cavaI82.211 Chronic embolism and thrombosis of superior vena cavaI82.290 Acute embolism and thrombosis of other thoracic veinsI82.291 Chronic embolism and thrombosis of other thoracic veinsI82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremityI82.402 Acute embolism and thrombosis of unspecified deep veins of left lower extremityI82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateralI82.411 Acute embolism and thrombosis of right femoral veinI82.412 Acute embolism and thrombosis of left femoral veinI82.413 Acute embolism and thrombosis of femoral vein, bilateralI82.421 Acute embolism and thrombosis of right iliac veinI82.422 Acute embolism and thrombosis of left iliac veinI82.423 Acute embolism and thrombosis of iliac vein, bilateralI82.431 Acute embolism and thrombosis of right popliteal veinI82.432 Acute embolism and thrombosis of left popliteal veinI82.433 Acute embolism and thrombosis of popliteal vein, bilateralI82.441 Acute embolism and thrombosis of right tibial veinI82.442 Acute embolism and thrombosis of left tibial veinI82.443 Acute embolism and thrombosis of tibial vein, bilateralI82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremityI82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremityI82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateralI82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremityI82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremityI82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateralI82.511 Chronic embolism and thrombosis of right femoral veinI82.512 Chronic embolism and thrombosis of left femoral veinI82.513 Chronic embolism and thrombosis of femoral vein, bilateralI82.521 Chronic embolism and thrombosis of right iliac veinI82.522 Chronic embolism and thrombosis of left iliac veinI82.523 Chronic embolism and thrombosis of iliac vein, bilateralI82.531 Chronic embolism and thrombosis of right popliteal veinI82.532 Chronic embolism and thrombosis of left popliteal veinI82.533 Chronic embolism and thrombosis of popliteal vein, bilateralI82.541 Chronic embolism and thrombosis of right tibial veinI82.542 Chronic embolism and thrombosis of left tibial veinI82.543 Chronic embolism and thrombosis of tibial vein, bilateralI82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremityI82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremityI82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateralI82.611 Acute embolism and thrombosis of superficial veins of right upper extremityI82.612 Acute embolism and thrombosis of superficial veins of left upper extremityI82.613 Acute embolism and thrombosis of superficial veins of upper extremity, bilateralI82.621 Acute embolism and thrombosis of deep veins of right upper extremityI82.622 Acute embolism and thrombosis of deep veins of left upper extremityI82.623 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 extremityI82.712 Chronic embolism and thrombosis of superficial veins of left upper extremityI82.713 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateralI82.721 Chronic embolism and thrombosis of deep veins of right upper extremityI82.722 Chronic embolism and thrombosis of deep veins of left upper extremityI82.723 Chronic embolism and thrombosis of deep veins of upper extremity, bilateralI82.811 Embolism and thrombosis of superficial veins of right lower extremitiesI82.812 Embolism and thrombosis of superficial veins of left lower extremitiesI82.813 Embolism and thrombosis of superficial veins of lower extremities, bilateralI82.890 Acute embolism and thrombosis of other specified veinsI82.891 Chronic embolism and thrombosis of other specified veinsI82.A11 Acute embolism and thrombosis of right axillary veinI82.A12 Acute embolism and thrombosis of left axillary veinI82.A13 Acute embolism and thrombosis of axillary vein, bilateralI82.A21 Chronic embolism and thrombosis of right axillary veinI82.A22 Chronic embolism and thrombosis of left axillary veinI82.A23 Chronic embolism and thrombosis of axillary vein, bilateralI82.B11 Acute embolism and thrombosis of right subclavian veinI82.B12 Acute embolism and thrombosis of left subclavian veinI82.B13 Acute embolism and thrombosis of subclavian vein, bilateralI82.B21 Chronic embolism and thrombosis of right subclavian veinI82.B22 Chronic embolism and thrombosis of left subclavian veinI82.B23 Chronic embolism and thrombosis of subclavian vein, bilateralI82.C11 Acute embolism and thrombosis of right internal jugular veinI82.C12 Acute embolism and thrombosis of left internal jugular veinI82.C13 Acute embolism and thrombosis of internal jugular vein, bilateralI82.C21 Chronic embolism and thrombosis of right internal jugular veinI82.C22 Chronic embolism and thrombosis of left internal jugular veinI82.C23 Chronic embolism and thrombosis of internal jugular vein, bilateralI83.011 Varicose veins of right lower extremity with ulcer of thighI83.012 Varicose veins of right lower extremity with ulcer of calfI83.013 Varicose veins of right lower extremity with ulcer of ankleI83.014 Varicose veins of right lower extremity with ulcer of heel and midfootI83.015 Varicose veins of right lower extremity with ulcer other part of footI83.018 Varicose veins of right lower extremity with ulcer other part of lower legI83.021 Varicose veins of left lower extremity with ulcer of thighI83.022 Varicose veins of left lower extremity with ulcer of calfI83.023 Varicose veins of left lower extremity with ulcer of ankleI83.024 Varicose veins of left lower extremity with ulcer of heel and midfootI83.025 Varicose veins of left lower extremity with ulcer other part of footI83.028 Varicose veins of left lower extremity with ulcer other part of lower legI83.11 Varicose veins of right lower extremity with inflammationI83.12 Varicose veins of left lower extremity with inflammationI83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammationI83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammationI83.213 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 andinflammation
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 andinflammation
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I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammationI83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammationI83.223 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 andinflammation
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 andinflammation
I83.811 Varicose veins of right lower extremities with painI83.812 Varicose veins of left lower extremities with painI83.813 Varicose veins of bilateral lower extremities with painI83.891 Varicose veins of right lower extremities with other complicationsI83.892 Varicose veins of left lower extremities with other complicationsI83.893 Varicose veins of bilateral lower extremities with other complicationsI83.91 Asymptomatic varicose veins of right lower extremityI83.92 Asymptomatic varicose veins of left lower extremityI83.93 Asymptomatic varicose veins of bilateral lower extremitiesI87.001 Postthrombotic syndrome without complications of right lower extremityI87.002 Postthrombotic syndrome without complications of left lower extremityI87.003 Postthrombotic syndrome without complications of bilateral lower extremityI87.011 Postthrombotic syndrome with ulcer of right lower extremityI87.012 Postthrombotic syndrome with ulcer of left lower extremityI87.013 Postthrombotic syndrome with ulcer of bilateral lower extremityI87.021 Postthrombotic syndrome with inflammation of right lower extremityI87.022 Postthrombotic syndrome with inflammation of left lower extremityI87.023 Postthrombotic syndrome with inflammation of bilateral lower extremityI87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremityI87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremityI87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremityI87.091 Postthrombotic syndrome with other complications of right lower extremityI87.092 Postthrombotic syndrome with other complications of left lower extremityI87.093 Postthrombotic syndrome with other complications of bilateral lower extremityI87.1 Compression of veinI87.2 Venous insufficiency (chronic) (peripheral)I87.301 Chronic venous hypertension (idiopathic) without complications of right lower extremityI87.302 Chronic venous hypertension (idiopathic) without complications of left lower extremity
I87.303 Chronic venous hypertension (idiopathic) without complications of bilateral lowerextremity
I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremityI87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremityI87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremityI87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremityI87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremityI87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity
I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lowerextremity
I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lowerextremity
I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lowerextremity
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 lowerextremity
I87.8 Other specified disorders of veinsI96 Gangrene, not elsewhere classified
I97.410 Intraoperative hemorrhage and hematoma of a circulatory system organ or structurecomplicating a cardiac catheterization
I97.411 Intraoperative hemorrhage and hematoma of a circulatory system organ or structurecomplicating a cardiac bypass
I97.418 Intraoperative hemorrhage and hematoma of a circulatory system organ or structurecomplicating other circulatory system procedure
I97.42 Intraoperative hemorrhage and hematoma of a circulatory system organ or structurecomplicating other procedure
I97.51 Accidental puncture and laceration of a circulatory system organ or structure during acirculatory system procedure
I97.52 Accidental puncture and laceration of a circulatory system organ or structure during otherprocedure
I97.610 Postprocedural hemorrhage of a circulatory system organ or structure following a cardiaccatheterization
I97.611 Postprocedural hemorrhage of a circulatory system organ or structure following cardiacbypass
I97.618 Postprocedural hemorrhage of a circulatory system organ or structure following othercirculatory system procedure
I97.620 Postprocedural hemorrhage of a circulatory system organ or structure following otherprocedure
I97.621 Postprocedural hematoma of a circulatory system organ or structure following otherprocedure
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 cardiaccatheterization
I97.631 Postprocedural hematoma of a circulatory system organ or structure following cardiacbypass
I97.638 Postprocedural hematoma of a circulatory system organ or structure following othercirculatory system procedure
I97.640 Postprocedural seroma of a circulatory system organ or structure following a cardiaccatheterization
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 othercirculatory system procedure
J96.01 Acute respiratory failure with hypoxiaJ96.02 Acute respiratory failure with hypercapniaL53.8 Other specified erythematous conditionsL53.9 Erythematous condition, unspecifiedL54 Erythema in diseases classified elsewhere
L76.01 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating adermatologic procedure
L76.02 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicatingother procedure
L76.11 Accidental puncture and laceration of skin and subcutaneous tissue during a dermatologicprocedure
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 dermatologicprocedure
L76.22 Postprocedural hemorrhage of skin and subcutaneous tissue following other procedureL97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skinL97.112 Non-pressure chronic ulcer of right thigh with fat layer exposedL97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscleL97.114 Non-pressure chronic ulcer of right thigh with necrosis of boneL97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skinL97.122 Non-pressure chronic ulcer of left thigh with fat layer exposedL97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscleL97.124 Non-pressure chronic ulcer of left thigh with necrosis of boneL97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skinL97.212 Non-pressure chronic ulcer of right calf with fat layer exposedL97.213 Non-pressure chronic ulcer of right calf with necrosis of muscleL97.214 Non-pressure chronic ulcer of right calf with necrosis of boneL97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skinL97.222 Non-pressure chronic ulcer of left calf with fat layer exposedL97.223 Non-pressure chronic ulcer of left calf with necrosis of muscleL97.224 Non-pressure chronic ulcer of left calf with necrosis of boneL97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skinL97.312 Non-pressure chronic ulcer of right ankle with fat layer exposedL97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscleL97.314 Non-pressure chronic ulcer of right ankle with necrosis of boneL97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skinL97.322 Non-pressure chronic ulcer of left ankle with fat layer exposedL97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscleL97.324 Non-pressure chronic ulcer of left ankle with necrosis of boneL97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skinL97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposedL97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscleL97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of boneL97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skinL97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposedL97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscleL97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of boneL97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skinL97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposedL97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscleL97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of boneL97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skinL97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposedL97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscleL97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of boneL97.811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skinL97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposedL97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscleL97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of boneL97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skinL97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposedL97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscleL97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone
13
M79.601 Pain in right armM79.602 Pain in left armM79.604 Pain in right legM79.605 Pain in left legM79.621 Pain in right upper armM79.622 Pain in left upper armM79.631 Pain in right forearmM79.632 Pain in left forearmM79.641 Pain in right handM79.642 Pain in left handM79.651 Pain in right thighM79.652 Pain in left thighM79.661 Pain in right lower legM79.662 Pain in left lower legM79.671 Pain in right footM79.672 Pain in left footM79.89 Other specified soft tissue disorders
M96.810 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating amusculoskeletal system procedure
M96.811 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating otherprocedure
M96.820 Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletalsystem procedure
M96.821 Accidental puncture and laceration of a musculoskeletal structure during other procedure
M96.830 Postprocedural hemorrhage of a musculoskeletal structure following a musculoskeletalsystem procedure
M96.831 Postprocedural hemorrhage of a musculoskeletal structure following other procedureO22.01 Varicose veins of lower extremity in pregnancy, first trimesterO22.02 Varicose veins of lower extremity in pregnancy, second trimesterO22.03 Varicose veins of lower extremity in pregnancy, third trimesterO22.11 Genital varices in pregnancy, first trimesterO22.12 Genital varices in pregnancy, second trimesterO22.13 Genital varices in pregnancy, third trimesterO22.21 Superficial thrombophlebitis in pregnancy, first trimesterO22.22 Superficial thrombophlebitis in pregnancy, second trimesterO22.23 Superficial thrombophlebitis in pregnancy, third trimesterO22.31 Deep phlebothrombosis in pregnancy, first trimesterO22.32 Deep phlebothrombosis in pregnancy, second trimesterO22.33 Deep phlebothrombosis in pregnancy, third trimesterO86.81 Puerperal septic thrombophlebitisO87.0 Superficial thrombophlebitis in the puerperiumO87.4 Varicose veins of lower extremity in the puerperiumQ27.31 Arteriovenous malformation of vessel of upper limbQ27.32 Arteriovenous malformation of vessel of lower limbQ27.39 Arteriovenous malformation, other siteQ27.8 Other specified congenital malformations of peripheral vascular systemR04.2 HemoptysisR04.89 Hemorrhage from other sites in respiratory passagesR06.00 Dyspnea, unspecifiedR06.02 Shortness of breathR07.1 Chest pain on breathing
14
R07.89 Other chest painR09.02 HypoxemiaR22.31 Localized swelling, mass and lump, right upper limbR22.32 Localized swelling, mass and lump, left upper limbR22.33 Localized swelling, mass and lump, upper limb, bilateralR22.41 Localized swelling, mass and lump, right lower limbR22.42 Localized swelling, mass and lump, left lower limbR22.43 Localized swelling, mass and lump, lower limb, bilateralR60.0 Localized edemaS35.514A Injury of right iliac vein, initial encounterS35.515A Injury of left iliac vein, initial encounterS35.59XA Injury of other iliac blood vessels, initial encounterS45.211A Laceration of axillary or brachial vein, right side, initial encounterS45.212A Laceration of axillary or brachial vein, left side, initial encounterS45.291A Other specified injury of axillary or brachial vein, right side, initial encounterS45.292A Other specified injury of axillary or brachial vein, left side, initial encounterS45.311A Laceration of superficial vein at shoulder and upper arm level, right arm, initial encounterS45.312A 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, initialencounter
S45.392A Other specified injury of superficial vein at shoulder and upper arm level, left arm, initialencounter
S55.211A Laceration of vein at forearm level, right arm, initial encounterS55.212A Laceration of vein at forearm level, left arm, initial encounterS55.291A Other specified injury of vein at forearm level, right arm, initial encounterS55.292A Other specified injury of vein at forearm level, left arm, initial encounterS75.111A Minor laceration of femoral vein at hip and thigh level, right leg, initial encounterS75.112A Minor laceration of femoral vein at hip and thigh level, left leg, initial encounterS75.121A Major laceration of femoral vein at hip and thigh level, right leg, initial encounterS75.122A Major laceration of femoral vein at hip and thigh level, left leg, initial encounterS75.191A Other specified injury of femoral vein at hip and thigh level, right leg, initial encounterS75.192A Other specified injury of femoral vein at hip and thigh level, left leg, initial encounterS75.211A Minor laceration of greater saphenous vein at hip and thigh level, right leg, initial encounterS75.212A Minor laceration of greater saphenous vein at hip and thigh level, left leg, initial encounterS75.221A Major laceration of greater saphenous vein at hip and thigh level, right leg, initial encounterS75.222A 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, initialencounter
S75.292A Other specified injury of greater saphenous vein at hip and thigh level, left leg, initialencounter
S85.311A Laceration of greater saphenous vein at lower leg level, right leg, initial encounterS85.312A 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, initialencounter
S85.392A Other specified injury of greater saphenous vein at lower leg level, left leg, initial encounterS85.411A Laceration of lesser saphenous vein at lower leg level, right leg, initial encounterS85.412A Laceration of lesser saphenous vein at lower leg level, left leg, initial encounterS85.491A Other specified injury of lesser saphenous vein at lower leg level, right leg, initial encounterS85.492A Other specified injury of lesser saphenous vein at lower leg level, left leg, initial encounterS85.511A Laceration of popliteal vein, right leg, initial encounterS85.512A Laceration of popliteal vein, left leg, initial encounter
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S85.591A Other specified injury of popliteal vein, right leg, initial encounterS85.592A Other specified injury of popliteal vein, left leg, initial encounterS95.211A Laceration of dorsal vein of right foot, initial encounterS95.212A Laceration of dorsal vein of left foot, initial encounterS95.291A Other specified injury of dorsal vein of right foot, initial encounterS95.292A Other specified injury of dorsal vein of left foot, initial encounterT38.4X5A Adverse effect of oral contraceptives, initial encounterT38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
T45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, initialencounter
T79.0XXAAir embolism (traumatic), initial encounterT79.1XXAFat embolism (traumatic), initial encounterT79.A11A Traumatic compartment syndrome of right upper extremity, initial encounterT79.A12A Traumatic compartment syndrome of left upper extremity, initial encounterT79.A21A Traumatic compartment syndrome of right lower extremity, initial encounterT79.A22A Traumatic compartment syndrome of left lower extremity, initial encounterT79.A3XATraumatic compartment syndrome of abdomen, initial encounterT79.A9XATraumatic compartment syndrome of other sites, initial encounterT80.0XXAAir embolism following infusion, transfusion and therapeutic injection, initial encounter
T80.1XXAVascular complications following infusion, transfusion and therapeutic injection, initialencounter
T80.810A Extravasation of vesicant antineoplastic chemotherapy, initial encounterT80.818A Extravasation of other vesicant agent, initial encounter
T80.89XA Other complications following infusion, transfusion and therapeutic injection, initialencounter
T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initialencounter
T81.32XA Disruption of internal operation (surgical) wound, not elsewhere classified, initial encounterT81.33XA Disruption of traumatic injury wound repair, initial encounterT81.4XXAInfection following a procedure, initial encounterT82.318A Breakdown (mechanical) of other vascular grafts, initial encounterT82.328A Displacement of other vascular grafts, initial encounterT82.338A Leakage of other vascular grafts, initial encounterT82.398A Other mechanical complication of other vascular grafts, initial encounterT82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial encounterT82.42XA Displacement of vascular dialysis catheter, initial encounterT82.43XA Leakage of vascular dialysis catheter, initial encounterT82.49XA Other complication of vascular dialysis catheter, initial encounterT82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounterT82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounterT82.520A Displacement of surgically created arteriovenous fistula, initial encounterT82.521A Displacement of surgically created arteriovenous shunt, initial encounterT82.523A Displacement of balloon (counterpulsation) device, initial encounterT82.524A Displacement of infusion catheter, initial encounterT82.525A Displacement of umbrella device, initial encounterT82.528A Displacement of other cardiac and vascular devices and implants, initial encounterT82.530A Leakage of surgically created arteriovenous fistula, initial encounterT82.531A Leakage of surgically created arteriovenous shunt, initial encounterT82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounterT82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounterT82.858A 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 encounterT82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounterT85.818A Embolism due to other internal prosthetic devices, implants and grafts, initial encounterT85.868A 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, initialencounter
Z01.818 Encounter for other preprocedural examination
Z09 Encounter for follow-up examination after completed treatment for conditions other thanmalignant neoplasm
Z86.711 Personal history of pulmonary embolismZ86.718 Personal history of other venous thrombosis and embolismZ86.72 Personal history of thrombophlebitisZ86.74 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 orS sequela may be used.
Group 2 Codes:
ICD-10Codes Description
I77.0 Arteriovenous fistula, acquiredN18.6 End stage renal diseaseT82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial encounterT82.42XA Displacement of vascular dialysis catheter, initial encounterT82.43XA Leakage of vascular dialysis catheter, initial encounterT82.49XA Other complication of vascular dialysis catheter, initial encounterT82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounterT82.520A Displacement of surgically created arteriovenous fistula, initial encounterT82.530A Leakage of surgically created arteriovenous fistula, initial encounterT82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter
T82.7XXAInfection and inflammatory reaction due to other cardiac and vascular devices, implantsand grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounterT82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounterT82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounterT82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounterT82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounterT82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initialencounter
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
17
hemodialysis access surgery Z01.818.
For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter orS sequela may be used.
Group 3 Codes:
ICD-10Codes Description
I74.2 Embolism and thrombosis of arteries of the upper extremitiesN18.4 Chronic kidney disease, stage 4 (severe)N18.5 Chronic kidney disease, stage 5N18.6 End stage renal diseaseT82.42XA Displacement of vascular dialysis catheter, initial encounterT82.43XA Leakage of vascular dialysis catheter, initial encounterT82.49XA Other complication of vascular dialysis catheter, initial encounterT82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounterT82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounterT82.520A Displacement of surgically created arteriovenous fistula, initial encounterT82.530A Leakage of surgically created arteriovenous fistula, initial encounterT82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter
T82.7XXAInfection and inflammatory reaction due to other cardiac and vascular devices, implantsand grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounterT82.828A Fibrosis due to vascular prosthetic devices, implants and grafts, initial encounterT82.838A Hemorrhage due to vascular prosthetic devices, implants and grafts, initial encounterT82.848A Pain due to vascular prosthetic devices, implants and grafts, initial encounterT82.858A Stenosis of other vascular prosthetic devices, implants and grafts, initial encounterT82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initialencounter
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
ICD-10 Additional Information
N/A
18
General Information
Associated Information
Documentation RequirementsAdequate documentation is essential for high-quality patient care and to demonstrate the reasonableness andmedical necessity of the study(ies). Documentation must support the criteria as described in the CoverageIndications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent recordof the performed studies and interpretation. The documentation should include a description of the studiesperformed and any contrast media and/or radiopharmaceuticals used. Any known significant patient reactionor complications should be recorded. Comparison with prior relevant studies needs to be addressed in thedocumentation along with both normal and abnormal findings. Variations from normal should be documentedalong with measurements. The report should address or answer any specific clinical questions. If there arefactors that prevent answering the clinical questions, this should be explained in the documentation. Retentionof the ultrasound examination images should be consistent both with clinical need and with relevant legal andlocal health care facility requirements.
If the provider of the study is other than the ordering/referring physician/nonphysician practitioner, thatprovider must maintain a copy of the test results and interpretation, along with copies of the ordering/referringphysician/nonphysician practitioner�s order for the studies. This order is required to provide adequatediagnostic information to the performing provider. The physician/nonphysician practitioner must state theclinical indication/medical necessity for the study in his/her order for the test. The provider is responsible forensuring the medical necessity of procedures and maintaining the medical record, which must be available toMedicare upon request. Results of all testing must be shared with the referring physician. Non-invasivevascular studies are medically reasonable and medically necessary only if the outcomes will be utilized in theclinical management of the patient.
Utilization GuidelinesEach patient�s condition and response to treatment must medically warrant the number of services reportedfor payment. Medicare requires the medical necessity for each study reported to be clearly documented in thepatient�s medical record.
Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility ofthe physician/provider to maintain documentation of medical necessity in the patient�s 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 amore current preoperative scan is indicated for a patient with multiple comorbidities having difficulty beingstabilized for surgery or a change in condition, the medical record would need to support the medicalnecessity of the second scan.
Only one limited study is considered reasonable and necessary post operatively within 72 hours of asaphenous 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 studieswhen the arterial studies demonstrate a non-acceptable conduit or an insufficient conduit is available formultiple bypass procedures.
Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic
19
studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. Thedocumentation must support the medical necessity.
Documentation must be provided supporting the need for more than one imaging study Doppler flow or vesselmapping and arteriogram.
Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veinsduring 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 themedical 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 venousultrasound 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 ultrasoundvascular mapping for the preoperative planning of dialysis access. American College of Radiology PracticeParameter. Resolution 39. pp.1-7.
ACR. (2011, Amended 2014). ACR-SPR-SRU Practice parameter for performing and interpreting diagnosticultrasound examinations. American College of Radiology. Resolution 39. pp.1-6.
ACR. (Revised 2014). ACR Practice parameter for communication of diagnostic imaging findings. AmericanCollege of Radiology Practice Parameter. Resolution 11. pp.1-9.
ACR. (Revised 2011). ACR Technical standard for diagnostic medical physics performance monitoring ofreal 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 vascularaccess outcomes in hemodialysis patients. Kidney International, 60:2013-2020.
Erickson, C.A., & et al. (1996, Jan). Ongoing vascular laboratory surveillance is essential to maximizelong-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-operativeevaluation prior to arteriovenous fistula formation for hemodialysis: Review of the evidence. NephrologyDialysis Transplantation, 23(6):1809-1815.
Gerhard-Herman, M., Gardin, JM., Jaff, M., Mohler, E., Roman, M., & Naqvi, T.Z. (2006, Aug). Guidelinesfor noninvasive laboratory testing: A report from the American Society of Echocardiography and the Societyof 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 TestingAccreditation. Page 1-67.
National Kidney Foundation (2006). KDOQI clinical practice guidelines and recommendations: hemodialysis
20
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 autogenoushemodialysis 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 hemodialysisaccess: A detailed protocol. International Journal of Nephrology. 2012(article no. 508956):1-7.
Revision History Information
RevisionHistory
Date
RevisionHistoryNumber
Revision History Explanation Reason(s) forChange
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 andT85.86XA. 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-GLto the list of accrediting bodies.
Revisions DueTo ICD-10-CMCode Changes
10/01/2015R4
06/01/2016 Annual review completed 05/06/2016. Correctedtypos. Added IOM references throughout document and removedunnecessary IOM references. Billing and Coding guideline isremoved.
Other (AnnualReview)
10/01/2015R3 04/01/2016 Added R06.00 to Group 1 Codes effective10/01/2015.
Other (Other �Added ICD-10codes)
Revisions DueTo ICD-10-CMCode Changes
10/01/2015R201/01/2016 Added I80.201, I80.202, I80.203, I82.401, I82.402,I82.403, I82.501, I82.502, I82.503, and Z09 to Group 1 Codeseffective 10/01/2015.
Other (Other �Added ICD-10codes)
10/01/2015R1 12/01/2015 Added the following codes to Group 1 Codeseffective 10/01/2015: L53.8, L53.9, L54 and M79.89. Added thefollowing statement to Group 1 Paragraph to clarify the codeswith a 7th digit of A, D, or S: For codes in the table below that
Other (AddedICD-10 codes)
21
require a 7th character, letter A initial encounter, Dsubsequent encounter or S sequela may be used. All 7th digitslisted in the Group 1 Codes table are now �A� with the ability touse �D� or �S� when coding the diagnosis. Removed the CACinformation.
Revisions DueTo ICD-10-CMCode Changes
Associated Documents
Attachments
N/A Related Local Coverage Documents
Article(s)
A54400 - Response to Comments: Non-Invasive Peripheral Venous Vascular and Hemodialysis AccessStudies
LCD(s)
L34536 - Treatment of Varicose Veins of the Lower Extremities Related National Coverage Documents
NCD(s)
20.14 - Plethysmography
220.5 - Ultrasound Diagnostic Procedures Public Version(s)
Updated on 09/19/2016 with effective dates 10/01/2016 - N/A
Article TitleResponse to Comments: Non-Invasive Peripheral Venous Vascular andHemodialysis Access Studies
Article TypeResponse to Comments
AMA CPT / ADA CDT / AHA NUBC Copyright StatementCPT only copyright 2002-2016 American Medical Association. All RightsReserved. CPT is a registered trademark of the American Medical Association.Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative valueunits, 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 doesnot directly or indirectly practice medicine or dispense medical services. The AMAassumes no liability for data contained or not contained herein.
The Code on Dental Procedures and Nomenclature (Code) is published in Current
22
Dental Terminology (CDT). Copyright © American Dental Association. All rightsreserved. CDT and CDT-2016 are trademarks of the American Dental Association.
UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, iscopyrighted by American Hospital Association (�AHA�), Chicago, Illinois. Noportion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical,photocopying, recording or otherwise, without prior express, written consent ofAHA.� Health Forum reserves the right to change the copyright notice from time totime upon written notice to Company.
Article Guidance
Article Text:
Response to Comments
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 thecomments.
Response to Comments
Response to Comments
Comment ResponseComments received stating that if the studies areperformed in the preoperative or pre-proceduralsetting, both physiologic studies and duplexscanning should be allowed at the same time asthis facilitates assessment of the adequacy ofrevascularization and serves as a baseline forpostoperative and post-procedural evaluation.These are often complimentary and not redundantstudies. Some of the patients come to us withstudies and we are unaware of the quality of themso we repeat all tests that are sent to us since weare making critical decisions affecting thepatient�s health from medical assessment,imaging or surgery.
All testing covered by Medicare must bemedically reasonable and necessary.Documentation must demonstrate why there was aneed for repeat testing or additional testing.
Podiatrists asked if a podiatrist chooses to onlyperform the technical (TC) and not theprofessional component (26), does this LCDqualifying criteria apply to the physician
Whether doing the TC or PC, physicians wouldneed to meet the criteria for qualification listed inthe policy. The physician performing the technicalcomponent would use the modifier TC and
23
performing the technical component independentor to the MD/DO vascular specialist interpretingthe evaluation data and making/confirming thediagnosis?
physician interpreting the results would bill usingmodifier 26 for professional services.
Comments received expressing concerns thatthere are surveillance protocols for patientspost-operatively, that has been shown in theliterature, to improve bypass graft patency ratesand should be covered without symptoms ofischemia.
Language and CPT codes were added to the policyto allow post-operative surveillance to becompleted provided that there is documentation tosupport the medical necessity of ordering thestudies.
Suggestions were made to make changes toCredentialing and Accreditation Standards oreliminate them altogether. While others expressedthe need for stricter requirements andenforcement due to potential adverse outcomesthat could result from inappropriately performedor interpreted studies.
Services will be considered medically reasonableand necessary only if performed by appropriatelytrained providers.
1. All non-invasive vascular diagnostic studiesmust be performed meeting at least one of thefollowing:
a. performed by a licensed qualified physician,or
b. performed by a technician who is certified invascular technology, or
c. performed in facilities with laboratoriesaccredited in vascular technology.
2. A licensed qualified physician for theseservices is defined as:
a. Having trained and acquired expertisewithin the framework of an accredited residencyor fellowship program in the applicablespecialty/subspecialty in ultrasound (US) or mustreflect equivalent education, training, andexpertise endorsed by an academic institution inultrasound or by applicable specialty/subspecialtysociety in ultrasound, or
b. Has the Registered Vascular Technologist(RVT), Registered Physician VascularInterpretation (RPVI), or ASN: NeuroimagingSubspecialty Certification; and
c. Is able to provide evidence of proficiency inthe performance and interpretation of each type ofdiagnostic procedure performed.
3. Nonphysician personnel performing testsmust demonstrate basic qualifications to performtests and have training and proficiency as
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evidenced by licensure or certification by anappropriate State health or education department.In the absence of a State licensing board,non-physician personnel must be certified by anappropriate national credentialing body.Appropriate personnel certification includes theAmerican Registry of Diagnostic MedicalSonographers (ARDMS), Registered VascularTechnologist (RVT) credential; or CardiovascularCredentialing International�s Registered VascularSpecialist (RVS).
4. Laboratories accredited by the IntersocietalAccreditation Commission (IAC), AmericanCollege of Radiology (ACR) Vascular UltrasoundProgram, or Joint Commission must follow theaccrediting body�s standards.
Podiatrists wrote that requiring a physician tohave staff privileges to interpret vascularlaboratory studies in a hospital or working in acertified vascular lab is neither a standard noruniversally required within states or by vascularorganizations, associations, or societies
It is not the intent of WPS to restrict the podiatricscope of practice. WPS uses Medicare�sdefinition of physicians which includes doctors ofpodiatric medicine. (CMS Pub 100-01 MedicareGeneral Information, Eligibility, and Entitlement,Chapter 5 � Definitions, Section 70.3 � Doctors ofPodiatric Medicine.) The section of the policy oncredentialing and accreditation standards has beenrevised.
Comments were received that the proposedrequirement that certified technologists directlysupervise and review the work of noncertifiedtechnologists as problematic.
We agree that the Medicare regulations dodescribe the requirements for physiciansupervision and defines general, direct, andpersonal supervision. We have removed thisstatement since the ultimate responsibility forsupervision and the quality of images is with thephysician.
The LCDs indicate, �it is recommended thatnoninvasive vascular studies either be rendered ina physician�s office by/or under the directsupervision of persons credentialed in the specifictype of procedure performed or performed inlaboratories accredited in the specific type ofevaluation.� The Medicare physician fee scheduleidentifies the services in these LCDs as requiringgeneral supervision, not direct. Any suggestionthat direct supervision of these services isrequired should be removed from the LCDs suchthat they are compatible with national policy.
We have removed this language.
Comments were received that stated thatIntersocietal Commission for Accreditation ofVascular Laboratories (ICAVL) is now theIntersocietal Accreditation Commission (IAC).The �ARRT� represents a radiologiccredentialing body (The American Registry of
Thank you. We have corrected IntersocietalAccreditation Commission (IAC) throughout thepolicy. We have added American College ofRadiology (ACR) to the list of credentialingboards. We removed the types of credentialing forindividuals that each organization offers.
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Radiologic Technologists. Absent from this list isthe American College of Radiology (ACR). ACRtechnologist certification should be added to thislist. The ACC supports participation in physiciancertification and/or laboratory accreditationprograms. Exceptions to mandates may benecessary to ensure that patients have access inunderserved areas.We are concerned the proposed LCDs do not givea timeframe for requiring accreditation. Werequest that you allow groups a three year periodwithin which they would become accredited.
Credentialing is not a new requirement. It was inthe previous LCD (L28586), Non-InvasiveVascular Testing (NIVT), which was originallyeffective 05/18/2009.
Comments were received that there is a lack ofpolicing the quality of the technicians andequipment with leads to repeating tests. Vascularlabs should be required to be certified rather thanwhat is currently in the policy that states the labsmay be certified. That would take care of thetechnician requirements.
The LCD outlines the requirements for theseprocedures. Documentation of credentialing andqualifications of staff could be reviewed on a postpay basis.
Comments were received regarding routinevenous mapping prior to bypass graft surgery notbeing covered. Commenters stated that it has beenshown to reduce complications and facilitateearlier discharge.
All testing covered by Medicare must bemedically reasonable and necessary.Documentation must demonstrate why there was aneed for additional testing.
A comment was received that each draft LCDmakes reference to documentation standards.While generally appropriate, some of thestandards quoted from an American College ofRadiology practice parameter would be overlyproscriptive if applied universally. That practiceparameter clearly states it would be inappropriateto take standards from an educational tool andapply them as �inflexible rules or requirements ofpractice.� The detailed, numbered documentationrequirements should be deleted.
We agree and the four detailed, numberedparameters from ACR have been removed. Thisalso removed the references to arterial segments.
Comment received that in the UtilizationGuidelines only one preoperative scan isconsidered reasonable and necessary for bypasssurgery, yet sometimes a second non-invasivevascular ultrasound is ordered rather than a CTAor MRA which are more expensive. If theoperative planning is occurring in a tight timeframe then only one scan might make sense. Butwhen you are dealing with patients with lots ofcomorbidities and trying to get them stable andready for surgery the data would be old and youneed to repeat a scan. Another physician statesthat the literature does not speak to an intervalwhen it would be appropriate to repeat the studiesbut it is based more on whether or not there is achange in patient symptoms that would
The following has been added to UtilizationGuidelines: Only one preoperative scan isconsidered reasonable and necessary for bypasssurgery. �If a more current preoperative scan isindicated for a patient with multiple comorbiditieshaving difficulty being stabilized for surgery or achange in condition, the medical record wouldneed to support the medical necessity of thesecond scan.�
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necessitate a reinvestigation.
The statement that duplex scanning andphysiologic studies may be reimbursed during thesame encounter if the physiologic studies areabnormal and/or to evaluate vascular trauma,thromboembolic events or aneurysmal disease isproblematic. Using the word �may� indicates thatjudgment will be used. If a group meets thecriteria you have established, they should bereimbursed. We urge you to change the word.
WPS has added the following paragraph toUtilization Guidelines: �Duplex scanning andphysiologic studies may be reimbursed during thesame encounter if the physiologic studies areabnormal and/or to evaluate vascular trauma,thromboembolic events or aneurysmal disease.The documentation must support the medicalnecessity.� The word �may� will continue to beused, because if it is determined to not bemedically necessity or the documentation does notsupport medical necessity, the studies would bedenied.
Received a statement that the policy states,�generally, it is expected that noninvasivevascular studies would not be performed morethan once in a year, excluding inpatient hospital(21) and emergency room (23) places of services.Comments noted that this was �not true of anAVF (arteriovenous fistula) that has maturationprocedures, and is being followed to assessimprovement vs. need for further intervention.�
All testing covered by Medicare must bemedically reasonable and necessary.Documentation must demonstrate why there was aneed for repeat testing or additional testing.
Only licensed MDs or DOs are allowed to sit forthe ARDMS RPVT examination, this functionallybarring all other individuals with licenses topractice medicine from sitting for theexamination.
Medicare does not set the requirements fororganizations that provide certifications forphysicians and technicians.
Comment received that nephrology and vascularaccess labs were not mentioned in thecredentialing and accreditation section of thepolicy.
None of the medical specialties were discussed inthis section. The physician must been therequirements of a licensed qualified physician andthe vascular lab must be accredited by one theaccrediting bodies recognized by CMS.
Comments were received regarding informationwritten in italics in the policy.
This italic information is taken directly out of theCMS Publication Manuals. WPS is not able tochange how this information is written.
Writer request that the following ICD 10 codes beadded to match the ICD 9 codes that are present.V12.51 Personal History of Venous Thrombosisand Embolism- ICD 10 Z86.718 V12.52 PersonalHistory of Thrombophlebitis- ICD 10 Z86.72V12.55 Personal History of PulmonaryEmbolism- ICD 10 Z86.711 V67.09 Follow upexamination other surgery- ICD 10 Z08 and Z09
Diagnostic codes Z86.711. Z86.718 and Z86.72are already the ICD 10 policy L35751. Z08 andZ09 will not be added to the policy since they areencounters for follow-up examination aftercompleted treatment for malignant neoplasm andfor conditions other than malignant neoplasm.
Related Local Coverage Document(s)
LCD(s)
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L35751 - Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies Related NationalCoverage Document(s)
NCD(s)
20.14 - Plethysmography
220.11 - Thermography
220.5 - Ultrasound Diagnostic Procedures
300.1 - Obsolete or Unreliable Diagnostic Tests
Public Version(s)
Updated on 06/25/2015 with effective dates 10/01/2015 - N/A
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