CPT code 93922 AND 93923, 93924 – Limited bilateral non invasive

by | Jun 28, 2012 | CPT modifiers

CPT Code Description

93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (e.g. forlower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume Plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels) (USV Lower Arterial ABI Only)
* 93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study
* (Do not report 93924 in conjunction with 93922, 93923)

93922: Medicare Part B local coverage determination (LCD) comment summary

CPT®93922 Limited bilateral noninvasive physiologic studies of upper or lower arteries (e.g. for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries with transcutaneous oxygen tension measurements at 1-2 levels)

** Use CPT®93922 as the default code for ABI studies

** CPT®93922 and CPT®93923 should not be ordered on the same request nor billed together for the same date of service.

** CPT®93924 and CPT®93922 and/or CPT®93923 should not be ordered on the same request and generally should not be billed together for the same date of service.

Reimbursment Guidelines
Reimbursement and coding information provided herein is gathered from third-party sources and is subject to change. This information is presented for illustrative purposes only. This information does not constitute reimbursement or legal advice, and is not intended as a guarantee of coverage or payment at any particular payment rate. CooperSurgical makes no representation or warranty regarding this information or its completeness, accuracy or timeliness. Laws, regulations and payer policies concerning reimbursement are complex and change frequently. The decision about which code(s) to report must be made by the billing provider/ physician considering the clinical facts, circumstances, and applicable coding rules. The code(s) selected should be supported by the contents of any clinical notes and/or chart documentation. Please contact your third-party payer for more specific guidance.
CPT® Code: 93922 Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries

Supervision:

General Supervision is defined as: “The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.” (PM B-01-28, April 29, 2001) CMS has determined the following list of procedures require general physician supervision effective July 1 2001:
93875 & TC, 93880 & TC, 93882 & TC, 93886 & TC, 93888 & TC, 93922 & TC, 93923 & TC, 93924 & TC, 93925 & TC, 93926 & TC, 93930 & TC, 93965 & TC, 93970 & TC, 93971 & TC (PM B-01-28, April 19, 2001) 
Coding Guidelines

1. Use the appropriate procedure code and modifiers.
2. Indicate the diagnoses for which the testing is being performed.
3. No paper documentation is required on initial claims submission unless required by an audit or the case deserves special case-by-case review. Place information on claim form as EMC narrative where indicated in the policy, e.g., follow-up studies.
4. Upper and lower extremity physiologic studies (CPT-4 codes 93922 and 93923), Lower extremity studies (CPT-4 codes 93925 and 93926), and Upper extremity duplex studies (CPT-4 codes 93930 and 93931)
If studies are performed on the upper and lower extremities on the same day, the services should be submitted on separate detail lines. When claims are submitted electronically, it should be indicated in Item19 of field N-4 (old format) or in record HAO-05 of the National Standard format, that upper AND lower studies were performed. If paper claims are still being submitted, this information must appear on the CMS-1500 claim form.
5. We will not permit separate payment for CPT code 93971 when G0365 is billed, unless CPT code 93971 is being performed for a separately identifiable indication in a different anatomic region. Other imaging studies may not be billed for the same site on the same date of service unless an appropriate “KX” modifier indicating the reason or need for the second imaging study is provided on the claim form. 

 Claudication

o “Since the presence and severity of arterial obstructions are reliably established using noninvasive hemodynamic tests such as the ankle brachial index (ABI), toe brachial index (TBI), segmental pressures, or pulse volume recordings (PVR), imaging studies are reserved for circumstances that warrant consideration for invasive therapy”

ABI (CPT®93922) is the preferred initial test

** Unless duplex ultrasound (CPT®93925 bilateral study or CPT®93926 unilateral study) is definitive, it should not replace ABI in determining the need for advanced imaging.

** If there is intermittent claudication, the ABI should be measured after exercise (CPT®93924) if the resting ABI is normal.

If ankle brachial index (ABI) and post-exercise ABI are normal, no advanced imaging is indicated.

CPT codes, descriptions, and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

Start Date of Comment Period:  10/07/2011

End Date of Comment Period: 11/21/2011

Comments received:

Comment #1: A comment was received in regard to the first bullet under the ‘Indications’ section of the draft LCD under ‘Indications and Limitations of Coverage and/or Medical Necessity’. This comment recommended that the following language, which has been struck-out, remain in the LCD: The diabetic patient with absent or diminished pulses with or without neuropathies may have no symptoms of claudication due to their neuropathy type symptoms. Additionally, it was recommended that the parameter of distance be removed from the first sentence of this bullet.

Contractor response: In accordance with language in the LCD, noninvasive studies will be considered medically reasonable and necessary for patients presenting with signs and symptoms that indicate a high likelihood of limb ischemia. While a diabetic patient may not exhibit signs and/or symptoms of claudication, the patient must present with evidence to raise suspicion of ischemic vascular disease as addressed in the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD to support the medical necessity for noninvasive vascular testing .

Comment #2: A comment was received that diabetic patients with arterial calcification may show falsely elevated ankle blood pressures; therefore, duplex scanning should not be precluded for this population of patients with ischemic signs or symptoms.

Contractor response: This situation is addressed in the ‘Limitations’ section of the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD which states: An ABI is not a separately reimbursable procedure when performed by itself and would be considered part of the physical examination. When the ABI is abnormal (i.e., <0.9 at rest), it must be accompanied by another appropriate indication before proceeding to more sophisticated or complete studies, except in patients with severely elevated ankle blood pressure.

In this regard, for diabetic patients with arterial calcification resulting in falsely elevated ankle blood pressures, a normal ABI would not preclude duplex scanning (CPT code 93925 or 93926) when ischemic signs or symptoms are present.

Comment #3: A comment was received to revise the second bullet under the ‘Indications’ section ‘under the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD as follows: Rest pain of ischemic origin (typically including the forefoot), associated with absent pulses, which becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent position.

Contractor response: This comment has been incorporated into the LCD.

Comment #4: A comment was received to revise the eighth bullet under the ‘Indications’ section ‘under the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD to always allow noninvasive vascular testing before an intervention and in the immediate post-operative period following an intervention or surgery in order to have a basis for comparison later. Additionally, noninvasive vascular testing should be allowed every six months after the first year following an intervention (i.e., bypass surgery or post-angioplasty).

Contractor response: The ‘Indications’ section of the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD addresses the typical timetable for follow-up studies in accordance with clinical guidelines. Specific findings should guide decisions for follow-up studies.

Comment #5: A comment was received that the ICD-9-CM codes in the LCD are too general and should be more aligned with the indications listed in the LCD.

Comment #6: A comment was received to clarify the language in the draft LCD concerning ‘uninterpretable’ studies, which is discussed in the ‘Limitations’ section of the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the draft LCD.

Contractor response: The intent of the language regarding ‘uninterpretable’ studies is to address the over-utilization of performing both the physiological study (93922, 93923, 93924) and the duplex scanning (93925, 93926) on the same date during the same encounter as a result of a physiological study that was of poor quality which resulted in the performance of a duplex scan. To provide clarification, this bullet will be revised to read: When an uninterpretable (i.e., poor quality or not in accordance with regulatory standards) non-invasive vascular study (93922, 93923, 93924) results in performing another type of non-invasive vascular study (93925, 93926), only the successful study should be billed.

Comment #7: A comment was received to clarify the language in the draft LCD concerning internal protocols of a testing facility, which is discussed in the ‘Limitations’ section of the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the draft LCD.

Contractor response: Per the CMS Online Manual, Pub 100-03, Medicare Benefit Policy Manual, Chapter 15, Section 80.6, noninvasive vascular procedures will not be covered when performed based on internal protocols of the testing facility as a referral for one non-invasive study is not a blanket referral for all studies and the provider treating the patient must specifically write an order for each procedure to be performed; therefore, when an interpreting physician at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate and that a different diagnostic test should be performed, the provider treating the patient must specifically write an order for another study to be performed.

Comment #8: A comment was received to remove the language in the draft LCD regarding limitations for the performance of both a physiological test (CPT codes 93922, 93923, 93924) and duplex scanning (CPT codes 93925, 93926) of extremity arteries during the same encounter as indicated in the ‘Limitations’ section under the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD.

Contractor response: This LCD has been revised based upon data and medical review of records which indicate frequent billing for both the physiological testing (CPT codes 93922, 93923, 93924) and duplex scanning (CPT codes 93925, 93926) of extremity arteries performed during the same encounter on a consistent basis, the medical necessity of which is not supported in the medical records. As noted in the LCD, in general, non-invasive studies of the arterial system are to be utilized when invasive correction is contemplated, but not to follow non-invasive medical treatment regimens (e.g., to evaluate pharmacologic intervention) or to monitor unchanged symptomatology. The latter may be followed with physical findings including ABIs and/or progression or relief of signs and/or symptoms. The rare circumstances which necessitate the performance of a physiologic study in addition to a duplex scan would need to be addressed on appeal.

Comment #9: A comment was received to remove the following language from the ‘Limitations’ section under the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of the LCD: Performance of both non-invasive extracranial arterial studies (CPT code 93880 or 93881) and non-invasive evaluation of extremity arteries (CPT codes 93922, 93923, 93924) during the same encounter is not appropriate as a general practice or standing protocol, and therefore, would not generally be expected. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter, and be available to Medicare upon request.

Contractor response: The language above reflects current practice guidelines (American College of Radiology, 2010); therefore, the medical record must clearly support the medical necessity for both non-invasive extracranial arterial studies and non-invasive evaluation of extremity arteries when these procedures are performed during the same encounter for the same patient as performance of both of these studies for the same patient on the same date of service is not typically expected.

Non-Invasive Physiologic Studies of Extremity Arteries
CPT®
*  Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries.
*  Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial 
indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement). 93922
* CPT® 93922 and CPT® 93923 can be requested and reported only once for the upper extremities and once for the lower extremities.
* CPT® 93922 and CPT® 93923 should not be ordered on the same request nor billed together for the same date of service.
* CPT® 93924 and CPT® 93922 and/or CPT® 93923 should not be ordered on the same request and should not be billed together for the same date of service.
* ABI studies performed with handheld dopplers, where there is no hard copy output for evaluation of bidirectional blood flow, are not reportable by these codes. 

PVD-1.3: General Guidelines – Imaging
* The Ankle Brachial Index (ABI) is a measurement that is calculated by dividing the systolic pressure at the ankle by the systolic pressure at the arm. This can be done at the bedside as part of the physical examination and if so does not need preauthorization. When the measurement includes printed Doppler waveforms and a
report pre-authorization may be needed (CPT® 93922 or CPT® 93923).
* ABI should be measured first:
* If normal, then further vascular studies are generally not indicated. 
PVD-2.1: Asymptomatic Screening
* Resting ABI (CPT® 93922) may be appropriate in an asymptomatic individual if the physical exam is consistent with significant PAD.
Background and Supporting Information
The incidence of PAD increases with age. Screening for PAD is important especially for individuals with diabetes and smokers, and is generally done as part of a good history and physical examination. Asymptomatic individuals with normal pulses generally do not need further testing to assess for PAD.
PVD-7.1: Claudication
* Resting ABI for initial evaluation for suspected PAD. This can be accomplished at the bedside as part of the physical examination or requested as CPT® 93922 (limited
Doppler ultrasound) or CPT® 93923 (multi-level complete Doppler ultrasound). CPT® 93923 may be performed once. Follow-up studies may be performed with CPT®
93922..
* Post-exercise ABI (CPT® 93924) can be performed if the resting ABI is > 0.89 and PAD is still highly suspected clinically.
* History and physical suggestive of PAD including:
* History
* Claudication
* Other non-joint-related exertional lower extremity symptoms (not typical of claudication)
* Impaired ability to walk
* Rest pain suggestive of ischemia
* Physical Examination
* Abnormal lower extremity pulse examination
* Vascular bruit
* Non-healing lower extremity wound
* Lower extremity gangrene
* Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor)
* If resting ABI (CPT® 93922) is normal (0.9 to 1.3) and disease is still suspected:
* Differentiate from “pseuodoclaudication” See SP-9: Lumbar Spinal Stenosis in the Spine Imaging Guidelines.
* Re-measure ABI after exercise (CPT® 93924).1
* A toe-brachial index may be used as further screening in individuals with ABI’s greater than 1.3.
* Otherwise, advanced imaging is necessary only if there is consideration for invasive therapy.2,3,4,5
* Duplex ultrasound (CPT® 93925 bilateral study or CPT® 93926 unilateral study) and Doppler studies are adjuncts to abnormal ABI that may be used to identify location
and extent of disease once there has been a decision for revascularization:6,7
* MRA Aorta, Pelvic vessels, and Lower extremities (CPT® 74185, CPT® 73725 and CPT® 73725), or CTA with run off (CPT® 75635) to further evaluate the lower
extremity arteries for any of the following:2,8
* ABI < 0.5
* Intermittent claudication (i.e. non-limb threatening ischemia) and either:
* Failed 3 months conservative medical therapy (physician supervised walking / exercise program plus medical therapy), or
* Functional disability (e.g. exercise impairment sufficient to threaten the individual’s employment or to require significant alterations in the individual’s
lifestyle)
* Potentially limb-threatening vascular disease evidenced by:
* Skin breakdown
* Non-healing ischemic ulcers
* Resting leg pain
* Gangrene
* Blue Toe Syndrome:
* Emboli from aortic plaque or mural thrombus
* Hyperviscosity syndrome
* Hypercoagulable states
* Vasculitis
* Preoperative planning for an invasive procedure (endovascular or open surgery).
* Note: MRA Pelvis should not be requested/billed with CPT® 74185, CPT® 73725 and CPT® 73725.
Background and Supporting Information Claudication symptoms usually remain stable (70% to 80% of individuals) and do not worsen or improve at rapid rates. Repeat studies to assess the efficacy of medical therapy are not indicated unless there is a negative change in clinical status.

Covered ICD CODE

250.70 Diabetes Mellitus with Peripheral Circulatory Disorders Type II or unspecified type not stated as uncontrolled
250.71 Diabetes Mellitus with Peripheral Circulatory Disorders Type I not stated as uncontrolled
250.72 Diabetes Mellitus with Peripheral Circulatory Disorders Type II or unspecified type uncontrolled
250.73 Diabetes Mellitus with Peripheral Circulatory Disorders Type I uncontrolled
353.00 Brachial plexus lesions
440.00 Atherosclerosis of aorta
440.20 Atherosclerosis of native arteries of the extremities unspecified
440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication
440.22 Atherosclerosis of native arteries of the extremities with rest pain
440.23 Atherosclerosis of native arteries of the extremities with ulceration
440.24 Atherosclerosis of native arteries of the extremities with gangrene
440.30 Atherosclerosis of bypass graft of the extremities
440.31 Atherosclerosis of autologous vein bypass graft of the extremities
440.32 Atherosclerosis of nonautologous bilogical bypass graft of the extremities
441.00 Dissection of aorta aneruysm unspecified site
441.01 Dissection of aorta thoracic
441.02 Dissection of aorta abdominal
441.03 Dissection of aorta thoracoabdominal
441.10 Thoracic aneurysm, ruptured
441.20 Thoracic aneurysm without mention of rupture
441.30 Abdominal aneurysm, ruptured
441.40 Abdominal aneurysm without mention of rupture
441.50 Aortic aneurysm of unspecified site, ruptured
441.60 Thoracoabdominal aneurysm, ruptured
441.70 Thoracoabdominal aneurysm, without mention of rupture
441.90 Aortic aneurysm of unspecified site without mention of rupture
442.00 Aneurysm of artery of upper extremity
442.20 Other aneurysm, of iliac artery
442.30 Aneurysm of artery of lower extremity
443.00 Raynaud’s syndrome
443.10 Thromboangiitis obliterans (Buerger’s disease)
443.81 Peripheral angiopathy in diseases classified elsewhere
443.89 Other specified peripheral vascular diseases
443.90 Peripheral vascular disease, unspecified
444.00 Arterial embolism and thrombosis of abdominal aorta
444.10 Arterial embolism and thrombosis of thoracic aorta
444.21 Arterial embolism and thrombosis of the upper extremity
444.22 Arterial embolism and thrombosis of the lower extremity
444.81 Embolism and thrombosis of iliac artery
444.89 Embolism and thrombosis of other artery
444.90 Embolism and thrombosis of unspecified artery
447.00 Arteriovenous fistula, acquired
447.10 Stricture of artery
447.20 Rupture of artery
707.10 Ulcer of lower limbs, except decubitus
707.11 Ulcer of thigh
707.12 Ulcer of calf
707.13 Ulcer of ankle Continued on Back Page
707.14 Ulcer of heel and midfoot
707.15 Ulcer of other part of foot
707.80 Chronic ulcer of other specified sites
747.60 Anomaly of the peripheral vascular system, unspecified site
747.63 Upper limb vessel anomaly
747.64 Lower limb vesel anomaly
785.40 Gangrene
903.00 Injury to axillary vessel(s) unspecified
903.01 Injury to axillary artery
903.02 Injury to axillary vein
903.10 Injury to brachial blood vessels
903.20 Injury to radial blood vessels
903.30 Injury to ulnar blood vessels
903.40 Injury to palmar artery
903.50 Injury to digital blood vessels
903.80 Injury to other specified blood vessels of upper extremity
903.90 Injury to Unspecified blood vessel of upper extremity
904.00 Injury to femoral artery
904.10 Injury to superficial femoral artery
904.20 Injury to Femoral veins
904.30 Injury to Saphenous veins
904.40 Injury to Popliteal vessel(s) unspecified
904.41 Injury to popliteal artery
904.42 Injury to Popliteal vein
904.50 Injury to Tibial vessel(s), unspecified
904.51 Injury to anterior tibial artery
904.52 Injury to Anterior tibial vein
904.53 Injury to posterior tibial artery
904.54 Injury to posterior tibial vein
904.60 Injury to deep plantar blood vessels
904.70 Injury to other specified blood vessels of lower extremity
904.80 Injury to Unspecified blood vessel of lower extremity
904.90 Injury to blood vesels of lower extremity and unspecified sites
996.10 Mechanical complications of other vascular device, implant, and graft
996.70 Other complications due to unspecified device implant and graft
996.71 Other complications due to heart valve prosthesis
996.72 Other complications due to other cardiac device implant and graft
996.73 Other complications due to renal dialysis device implant and graft
996.74 Other complications due to other vascular device implant and graft
996.75 Other complications due to nervous system device implant and graft
996.76 Other complications due to genitourinary device implant and graft
996.77 Other complications due to internal joint prosthesis
996.78 Other complications due to other internal orthopedic device implant and graft
996.79 Other complications due to other internal prosthetic device implant and graft
998.11 Hemorrhage complicating a procedure
998.12 Hematoma complicating a procedure
998.13 Seroma complicating procedure
998.20 Atherosclerosis of native arteries of the extremities
V42.0 Organ or tissue replaced by transplant, Kidney