Non-Invasive Peripheral Venous Studies ( L34714 ) Coverage Guidance



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 patient's 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 data 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 (CPT/HCPCS codes 93970, 93971, G0365)
•    Doppler waveform analysis including responses to compressions and other maneuvers (CPT code 93965)
•    Impedance Plethysmography (CPT code 93965)
•    Air Plethysmography (CPT code 93965)
•    Strain Gauge Plethysmography (CPT code 93965)
Indications

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

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 variable and may be absent. 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 a documented pulmonary embolism.
•    The index of suspicion is raised for subsequent DVT in individuals with past history of DVT, pulmonary embolus or documented genetic or acquired coagulation factor aberration.
•    Unexplained extremity edema, especially, unilateral, in an individual at risk for DVT (e.g., immobile, status-post major surgical procedure or injury, indwelling vascular catheter or prosthesis, or postpartum)
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 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 usually medically necessary to study asymptomatic varicose veins. However, if a great or small saphenous vein undergoes ablation, a duplex scan of the affected side may be reasonable and necessary postoperatively within 72 hours after the procedure, to assess the result of the surgery and the possibility of propagation of a thrombus.

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

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, the Registered Cardiovascular Technologist (RCVT) credential in Vascular Technology, and the Vascular Sonographer (VS) awarded certification by the ARRT. 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 lower extremity 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
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

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