Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27506

Non-Invasive Peripheral Venous Studies

L27506

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Internet On-line Manual Pub. 100-3, Chapter 1, Section 20.14 is specific to Plethysmography.

CMS Internet On-line Manual Pub. 100-3, Chapter 1, Section 20.17 is specific to Non-Invasive Tests of Carotid function.

CMS Internet On-line Manual Pub. 100-3, Chapter 1, Section 220.5 is specific to Ultrasound Diagnostic Procedures.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Vascular studies include patient care required to perform the studies; supervision of the studies; and interpretation of study results, with copies for patients’ records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided. (A hard copy, or a soft copy convertible to a hard copy, provides a permanent record of the study performed and must be of a quality that meets accepted radiologic standards.)

The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reimbursable. Doppler procedures performed with zero-crossers (i.e., analog [strip chart recorder] analysis) are also included in the office visit.

A duplex scan implies an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time, and Doppler ultrasonic signal documentation with spectrum analysis and/or color flow velocity mapping or imaging.

A physiologic study implies functional measurement procedures including Doppler ultrasound studies, blood pressure measurements, transcutaneous oxygen tension measurements, or plethysmography.

Plethysmography implies volume measurement procedures including air, impedance, or strain gauge methods.

Acceptable Procedures For Reimbursement

• Duplex scan (93970, 93971, G0365)
• Doppler waveform analysis including responses to compressions and other maneuvers (93965)
• Impedance Plethysmography (93965)
• Air Plethysmography (93965)
• Strain Gauge Plethysmography (93965)

Indications

Indications for venous examinations are separated into the following categories: deep vein thrombosis (DVT), chronic venous insufficiency, and preoperative venous mapping.

Deep Vein Thrombosis (DVT)

DVT is the most common vascular disorder that develops in hospitalized patients, and can develop after trauma or prolonged immobility (sitting or bedrest). The signs and/or symptoms of DVT are relatively non-specific. Due to the risk associated with pulmonary embolism (PE), objective testing is allowed in patients that are candidates for anticoagulation or invasive therapeutic procedures for the following indications:

• Clinical signs and/or symptoms of acute or new onset DVT such as extremity swelling, tenderness, inflammation and/or erythema.
• Investigation for DVT as the source of the pulmonary embolism
• Unexplained lower extremity edema with high pre-test probability of DVT (e.g., status-post major surgical procedure or postpartum)
• High risk patients: hip surgery, multiple trauma, malignancy, etc.

Bilateral limb edema, especially when signs and/or symptoms of congestive heart failure, exogenous obesity and/or arthritis are present, should rarely be an indication for venous studies.

Chronic Venous Insufficiency

Chronic venous insufficiency may be divided into several categories; objective testing is allowed in patients that are candidates for anticoagulation or invasive therapeutic procedures for the following indications:

• Post-Thrombotic (Post Phlebitic) Syndrome - Evaluation is medically necessary in patients with symptoms of post-thrombotic syndrome.
• Recurrent DVT - Evaluation is medically necessary in patients with signs or symptoms of recurrent DVT.
• Objective tests of venous function may be indicated in patients with ulceration, thickening and discoloration suspected to be secondary to venous insufficiency in order to confirm this diagnosis, by documenting venous valvular incompetence, prior to treatment.

Primary Varicose Veins - It is not medically necessary to study asymptomatic varicose veins.

Preoperative Examinations

Non-Invasive Peripheral Venous Studies may also be medically necessary for select preoperative examinations.

• Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (CPT code 93971) 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 bypass surgery must be determined prior to performance of the test. Only one preoperative scan is covered for bypass surgery.
• Vessel mapping of vessels for hemodialysis (HCPCS code G0365) is indicated for the preoperative examination of vessels prior to hemodialysis access site surgery 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 (i.e., when the patient’s clinical evaluation does not readily lead to the selection of a vein that is suitable for creating a dialysis fistula). The need for a hemodialysis access site must be determined prior to performance of the test. Only one preoperative scan is covered per hemodialysis access site surgery.

Limitations

The accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and physician performing and interpreting the study. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience and maintain documentation for postpayment audit. A vascular diagnostic study may be personally performed by a physician or a technologist. All noninvasive vascular diagnostic studies performed by a technologist must be performed by, or under the direct supervision of, a technologist who has demonstrated competency by being credentialed in vascular technology, or, such studies must be performed in a facility accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) or the Non-Invasive Vascular Ultrasound Accreditation of the American College of Radiology. Examples of appropriate certification include the Registered Vascular Technologist (RVT) credential and the Registered Cardiovascular Technologist (RCVT) credential in Vascular Technology. Direct supervision requires the credentialed individual’s presence in the facility and immediate availability to the technologist performing the study.

Medicare does not pay for routine screening tests. ICD-9-CM diagnosis code V82.9 (special screening of other conditions, unspecified condition) should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of ICD-9-CM code V82.9 will result in the denial of claims as non-covered screening services.

It is rarely necessary to perform cerebrovascular and upper extremity studies on the same day. Documentation supporting the need for both studies should be available for review.

As stated above, bilateral limb edema, especially when signs and/or symptoms of congestive heart failure, exogenous obesity and/or arthritis are present, should rarely be an indication for venous studies. Primary Varicose Veins - It is not medically necessary to study asymptomatic varicose veins. Any preoperative indication not listed as indicated under "Indications and Limitations of Coverage" will be denied based on medical necessity.

The following methods are not covered:

• Mechanical Oscillometry
• Inductance Plethysmography
• Capacitance Plethysmography
• Photoelectric Plethysmography

Diagnostic Tests and X-Rays

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.

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

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
   
   
4. Documentation must be provided supporting the need for more than one imaging study (Doppler flow (93990) and arteriogram (75790/75820).

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

• Only one preoperative scan is covered for bypass surgery. 
• Only one preoperative scan is covered per hemodialysis access site surgery.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27506

05/22/2008

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