CPT 93975, 93976, 93978 - Non invasive abdominal vascular study

Procedure code and Description


Group 1 Codes:

93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY

93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY

93978 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY

93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY

93980 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; COMPLETE STUDY


93981 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; FOLLOW-UP OR LIMITED STUDY

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity


Overview

Non-invasive abdominal/visceral vascular studies utilize ultrasonic Doppler and physiologic principles to assess the irregularities in blood flow in renal, iliac, and femoral artery systems. These tests are also used to diagnose aortic aneurysms. Noninvasive abdominal/ visceral vascular studies include the patient care required to perform the studies, supervision of the studies, and interpretation of study results, with copies for patient records of test results and analysis of all data, including bi-directional vascular flow or imaging when provided.

Diagnostic tests must be ordered by the physician who is treating the beneficiary and who will use the results in the management of the beneficiary’s specific medical problem. Services are deemed medically necessary when all of the following conditions are met:
Signs/symptoms of ischemia or altered blood flow are present;

The information is necessary for appropriate medical and/or surgical management;

The test is not redundant of other diagnostic procedures that must be performed. Although, in some circumstances, non-invasive vascular tests are complimentary, such as MRA and duplex, where the latter may confirm an indeterminate finding or demonstrate the physiologic significance of an anatomic stenosis such as in renal, iliac, and/or femoral arteries.



Definitions:

Duplex Scans: Duplex combines Doppler and conventional ultrasound, allowing the structure of blood vessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to be seen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds into colors overlaid on the image, representing information about the speed and direction of blood flow. Using spectral Doppler analysis, the duplex scan images provide anatomic and hemodynamic information, identifying the presence of any stenosis or plaque in the arteries. Duplex scans are in real-time.

Abdominal/Visceral Vascular Studies 

Abdominal/visceral non-invasive vascular studies are indicated in the evaluation and /or management of vascular disease along with, the narrowing or blockage of arteries that supply blood to the abdomen including intestines (mesenteric vascular disease), pelvic and scrotal contents, and/or retroperitoneal organs including the kidneys (renal vascular disease).
Abdominal, Retroperitoneal and Pelvic Organs (93975, 93976)
Indications:
Uncontrolled hypertension.

Stenosis of visceral artery (atherosclerotic, fibromuscular dysplasia, vasculitis, functional).

Aneurysm of visceral artery.

Portal hypertension, with or without ascites.

Cirrhosis of the liver.

Venous embolism, hemorrhage, infection, and/or thrombosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Stenosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Complications of internal (biological) (synthetic) prosthetic device implant and/or graft.

Complications in abdominal organ or tissue transplant.

Pain or swelling of scrotal contents which may be a result of suspected obstruction in arterial inflow or venous outflow to testicles or related structure.

Torsion of the spermatic cord; acute epididymitis or epididymoorchitis; or torsion of the testicular appendages.

Hypertension and normotensive renovascular disease with impaired renal function which could be acute kidney failure, chronic kidney disease, end stage renal disease, or other vascular disorders of the kidneys.

Pain or swelling of the female genital organs which may be the result of torsion of the ovaries, ovarian pedicle or fallopian tube.

Trauma to the abdominal, retroperitoneal and/or pelvic organs, arteries, and /or veins.


Aorta, Inferior vena cava, Iliac Vasculature and Bypass grafts (93978, 93979)
Indications:
Atherosclerosis of aorta.

Atherosclerosis of the extremities with intermittent claudication.

Atherosclerosis of other specified arteries.

Aortic aneurysm and dissection.

Aneurysm of iliac artery.

Thromboangiitis obliterans (Buerger’s disease).

Peripheral vascular disease unspecified.

Arterial embolism and thrombosis of abdominal aorta.

Arterial embolism and thrombosis of iliac artery.

Phlebitis and thrombophlebitis of iliac vein.

Venous embolism and thrombosis of vena cava.

Complications related to surgical procedures involving prosthetic device implant, graft, and/or shunts.

Complications of organ or tissue transplant.

Trauma to the chest wall and /or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

Limitations:

Vascular studies are not the initial diagnostic modality for the evaluation of abdominal pain/tenderness. There must be a high index of suspicion that the pain is caused by a vascular disorder, such as mesentery ischemia.

Routine imaging of the iliac veins is not medically necessary. Exceptions will be made for specific medical indications of possible propagation of a known thrombus for consideration for placement of a vena cava filter device via the femoral approach. The medical necessity must be documented in the medical record.

Abdominal aortic aneurysms > four cm in diameter may be followed with abdominal ultrasound every six months. Documentation of medical necessity needs to be provided for studies performed more frequently.

The outcome must impact the clinical management of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of the noninvasive studies, the non-invasive vascular studies are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.


Duplex scanning in the evaluation of an abdominal aortic aneurysm is of limited value unless there is a pulsatile abdominal mass and signs and symptoms of peripheral vascular disease are present.

Noninvasive vascular studies are medically necessary only if the outcome will potentially impact the clinical course of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of noninvasive studies, noninvasive vascular procedures are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.

The accuracy of noninvasive vascular diagnostic studies depends on the knowledge, skills and experience of the technologist and interpreter. Consequently, the providers of interpretations must be capable of demonstrating documented training and experience and maintain documentation of such for possible audit. Further, noninvasive vascular diagnostic studies must be either (1) performed by persons with appropriate training that have demonstrated minimum entry level competency by being credentialed by a nationally recognized credentialing organization in vascular technology (e.g., American Registry of Radiologic Technologists (ARRT) in vascular technology), (2) performed by or under the direct supervision of a physician, or (3) performed in facilities with laboratories accredited in vascular technology.

Penile Vascular Studies (93980, 93981)

Duplex scans of the arterial inflow and venous outflow of penile vessels, have no therapeutic implications. Therefore, they are considered not medically reasonable or necessary, except in a patient with treatment failure who has sustained a documented groin injury where a vascular etiology for impotence is suspected.

Credentialing and Accreditation Standards

The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience. A vascular diagnostic study may be personally performed by a physician, a certified technologist, or in a certified vascular testing lab.

Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

All non-invasive vascular diagnostic studies must be performed meeting at least one of the following:
performed by a licensed qualified physician, or

performed by a technician who is certified in vascular technology, or

performed in facilities with laboratories accredited in vascular technology.

A licensed qualified physician for these services is defined as:
Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or

Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and

Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed.

Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body.

Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing International’s Registered Vascular Specialist (RVS).

Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) Vascular Ultrasound Program, Joint Commission or DNV-GL must follow the accrediting body’s standards.


Doppler or Duplex Ultrasound

Aorta, Inferior Vena Cava, Iliac Vessel Duplex - 93978, 93979


General Reminders And Billing Guidelines

1. Confirm the type of study being requested.  Ultrasound will look at soft tissues or organs.  A Doppler or Duplex ultrasound evaluates blood vessels noting both the speed and direction of blood flow. 

2. Confirm the type of blood vessel you are evaluating (arteries or veins) as NIA manages both Arterial Duplex and Venous Duplex Scans.

3. Make sure the study requested images the correct area or organ.  For example, an ultrasound of the liver would not be accomplished with a Pelvic Ultrasound.

4. Make sure notes support or justify the request by providing an adequate description of symptoms, exam findings, prior imaging results, and reason for the requested study. 

5. Ultrasound imaging would typically be performed prior to advanced imaging (CT or MRI) not simultaneously. 

Coding Tips

1. A head and neck ultrasound is not used to evaluate structures inside an infants head such as bleeding on the brain, excess fluid accumulation, enlarged skull size, etc.  This is correctly coded using CPT code 76505 which is an echoencephalogram sometimes referred to as a neonatal intracranial ultrasound.  NIA does not precertify this request.

2. We do not manage prenatal ultrasounds (ultrasound of the fetus in a pregnant patient) or transvaginal ultrasounds. 

3. ABI studies or ankle-brachial index studies are typically coded with CPT codes 93922, 93923, and 93924.  NIA does not manage these requests.

4. Post void residual studies (PVR) which measure the amount of urine remaining in the bladder after urination are coded with CPT code 51798.  NIA does not manage this study.

5. An Abdominal ultrasound, CPT code 76770, can be considered a complete study when being used for urinary indications and must image the kidneys and bladder

FIRST COAST SERVICE OPTIONS MEDICARE PART B LOCAL COVERAGE DETERMINATION

93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study

Aorta, inferior vena cava, iliac vasculature, or bypass grafts (procedure codes 93978 and 93979) Connecticut and Florida Medicare may provide coverage for duplex scanning of aorta, inferior venacava, iliac vasculature, or bypass grafts when performed for one or more of the following indications:

• confirm a suspicion of an abdominal or iliac aneurysm raised by a physical examination or noted as an incidental finding on another radiological examination. The physical examination usually reveals a palpable, pulsatile and nontender abdominal mass;

• monitor the progression of an abdominal aortic aneurysm. It is usually expected that monitoring occurs approximately every six (6) months;

• evaluate patients presenting with signs and symptoms of a thoracic aneurysm. The symptoms usually associated with a thoracic aneurysm are substernal chest pain, back or neck pain described as deep and aching or throbbing as well as symptoms due to pressure on the trachea (dyspnea, stridor, a brassy cough), the esophagus (dysphagia), the laryngeal nerve (hoarseness), or superior vena cava (edema in neck and arms, distended neck veins);

• evaluate patients presenting with signs and symptoms of an abdominal aneurysm. The symptoms usually associated with an abdominal aneurysm are constant pain located in the midabdomen, lumbar region or pelvis which can be severe and may be described as having a boring quality. A leaking aneurysm is characterized by lower back pain, whereas, acute pain and hypotension usually occur with rupture;

• evaluate a patient presenting with signs and symptoms suggestive of an aortic dissection. A patient with an aortic dissection has symptoms such as a sudden onset of severe, continuous tearing or crushing pain in the chest that radiates to the back and is generally unaccompanied by EKG evidence of a myocardial infarction. On physical examination, the patient is agitated, has a murmur of aortic regurgitation.


ICD-10 Codes that Support Medical Necessity

Group 1Codes

ICD-10 CODE DESCRIPTION

I10 Essential (primary) hypertension

I11.0 Hypertensive heart disease with heart failure

I11.9 Hypertensive heart disease without heart failure

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I15.0 Renovascular hypertension

I15.1 Hypertension secondary to other renal disorders

I15.2 Hypertension secondary to endocrine disorders

I15.8 Other secondary hypertension

I70.1 Atherosclerosis of renal artery


I71.1 Thoracic aortic aneurysm, ruptured

I71.2 Thoracic aortic aneurysm, without rupture

I71.3 Abdominal aortic aneurysm, ruptured

I71.4 Abdominal aortic aneurysm, without rupture

I71.5 Thoracoabdominal aortic aneurysm, ruptured

I71.6 Thoracoabdominal aortic aneurysm, without rupture

I72.2 Aneurysm of renal artery

I72.8 Aneurysm of other specified arteries

I74.01 Saddle embolus of abdominal aorta

I74.09 Other arterial embolism and thrombosis of abdominal aorta

I74.10 Embolism and thrombosis of unspecified parts of aorta

I74.19 Embolism and thrombosis of other parts of aorta

I74.5 Embolism and thrombosis of iliac artery

I74.8 Embolism and thrombosis of other arteries

I75.81 Atheroembolism of kidney

I75.89 Atheroembolism of other site

I76 Septic arterial embolism

I77.2 Rupture of artery

I77.3 Arterial fibromuscular dysplasia

I77.4 Celiac artery compression syndrome

I77.73 Dissection of renal artery

I77.79 Dissection of other specified artery

I77.810 Thoracic aortic ectasia

I77.811 Abdominal aortic ectasia

I77.812 Thoracoabdominal aortic ectasia

I77.819 Aortic ectasia, unspecified site

I80.8 Phlebitis and thrombophlebitis of other sites

I81 Portal vein thrombosis

I82.0 Budd-Chiari syndrome

I82.1 Thrombophlebitis migrans

I82.210 Acute embolism and thrombosis of superior vena cava

I82.211 Chronic embolism and thrombosis of superior vena cava

I82.290 Acute embolism and thrombosis of other thoracic veins

I82.291 Chronic embolism and thrombosis of other thoracic veins

I82.3 Embolism and thrombosis of renal vein

I86.1 Scrotal varices

I86.2 Pelvic varices

I86.3 Vulval varices

I86.4 Gastric varices

I86.8 Varicose veins of other specified sites

K55.011 Focal (segmental) acute (reversible) ischemia of small intestine

K55.012 Diffuse acute (reversible) ischemia of small intestine

K55.019 Acute (reversible) ischemia of small intestine, extent unspecified

K55.021 Focal (segmental) acute infarction of small intestine

K55.022 Diffuse acute infarction of small intestine

K55.029 Acute infarction of small intestine, extent unspecified

K55.031 Focal (segmental) acute (reversible) ischemia of large intestine

K55.032 Diffuse acute (reversible) ischemia of large intestine

K55.039 Acute (reversible) ischemia of large intestine, extent unspecified

K55.041 Focal (segmental) acute infarction of large intestine

K55.042 Diffuse acute infarction of large intestine

K55.049 Acute infarction of large intestine, extent unspecified

K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified

K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified

K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified

K55.061 Focal (segmental) acute infarction of intestine, part unspecified

K55.062 Diffuse acute infarction of intestine, part unspecified

K55.069 Acute infarction of intestine, part and extent unspecified

K55.1 Chronic vascular disorders of intestine

K55.30 Necrotizing enterocolitis, unspecified

K55.31 Stage 1 necrotizing enterocolitis

K55.32 Stage 2 necrotizing enterocolitis

K55.33 Stage 3 necrotizing enterocolitis

K55.8 Other vascular disorders of intestine

K70.2 Alcoholic fibrosis and sclerosis of liver

K70.30 Alcoholic cirrhosis of liver without ascites

K70.31 Alcoholic cirrhosis of liver with ascites

K74.0 Hepatic fibrosis

K74.60 Unspecified cirrhosis of liver

K74.69 Other cirrhosis of liver

K76.6 Portal hypertension

N17.0 Acute kidney failure with tubular necrosis

N17.1 Acute kidney failure with acute cortical necrosis

N17.2 Acute kidney failure with medullary necrosis

N17.8 Other acute kidney failure

N17.9 Acute kidney failure, unspecified

N18.1 Chronic kidney disease, stage 1

N18.2 Chronic kidney disease, stage 2 (mild)

N18.3 Chronic kidney disease, stage 3 (moderate)

N18.4 Chronic kidney disease, stage 4 (severe)

N18.5 Chronic kidney disease, stage 5

N26.1 Atrophy of kidney (terminal)

N26.2 Page kidney

N26.9 Renal sclerosis, unspecified

N27.0 Small kidney, unilateral

N27.1 Small kidney, bilateral


Inferior Cava / Iliac Vein Duplex Protocol

* Verify patient, order and indication for examination.

* Patients undergoing IVC-iliac segment evaluation are generally ask to fast prior to this exam to minimize bowel gas if this proves necessary.

* Explain basic test procedure to patient in order to minimize anxiety.

* A focused history and physical exam should be performed.

* Hard copy is a combination of video tape and/or still images – PLEASE REFER TO REQUIRED

DOCUMENTATION. If stills only, please make sure to document thoroughly!

* The patient is placed in a supine position and the exam is begun at the midline just below the xiphoid process. The low frequency curvilinear transducer is most often employed but the linear transducer can provide excellent images if depth requirements are not too great. Abdominal exams generally require various acoustic windows and patient positions in order to optimize the data available from a patient. These vary from patient to patient depending upon anatomy, body habitus, recent (or even remote) surgery, and mostly the presence and location of bowel gas.

* The examination is begun at the IVC at the level of the diaphragm and followed distally to the confluence. Longitudinal and transverse images should be used to confirm findings.

* From the IVC confluence, the common iliac veins are followed distally, if possible noting the confluence of the internal iliac vein. If difficulty is encountered, it is often helpful to begin by locating the external iliac vein at the groin and following it proximally.

* Each vessel is evaluated for patency, color flow filling to help confirm patency, and notable flow changes.

* Pay close attention to any evidence of extrinsic compression. Measure and report any suspected compression.

* A representative spectral analysis of each vessel should be taken at a good (60 degrees or less) Doppler angle in each vein segment looking for a spontaneous and phasic flow pattern.

* Spectral analysis should also be obtained at any noted color flow changes or at any imaged abnormality.

* Proximal augmentation maneuvers, (ie: deep inspiration, valsalva) can be performed to help demonstrate proximal patency and reflux. Distal augmentation, (ie: common femoral or thigh compression) should also be performed to ascertain distal patency and competence.
Inferior Vena Cava and Iliac Venous Duplex Examination Required Documentation

Gray scale and / or Color Doppler Images Include gray scale only images if pertinent, significant disease or otherwise deemed necessary. These could also be incorporated into the spectral analysis if data quality is good and well visualized – and especially if normal.)

1. Inferior vena cava - multiple transverse and longitudinal planes

a. Proximal (window through the liver)

b. Mid / Distal

c. Confluence if possible

2. Common iliac vein (iliac images can often be combined )

a. Make sure to carefully evaluate and if applicable, measure the CIV if iliac vein compression is identified

3. External iliac vein
4. Internal iliac vein if possible
5. Any areas of suspected obstruction, extrinsic compression, or other abnormality
6. Any other measurements performed

Spectral Doppler

1. IVC - document if normal and if not or suspicious, then proximal, distal and any suspect areas
2. Common iliac vein
3. External iliac vein
4. Internal iliac vein if possible
5. Any areas of suspected obstruction, extrinsic compression, or other abnormality

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