CPT code 97375, 93976, 93978 - Non invasive vascular studies

Procedure Codes

93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study

93976 limited study

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

93979 unilateral or limited study


INTRODUCTION:

A Duplex scan is an ultrasonic scanning procedure used to characterize the pattern and direction of blood flow in arteries or veins with the production of real-time images. While duplex ultrasound is a relatively safe and widely available modality it does have its particular shortcomings and specific indications.

Obtaining a high quality study requires the interplay of a number of factors. There are established criteria that are important to consider in order to ensure reliable, interpretable and meaningful results. Renal Artery imaging involves the use of color Doppler to access flow disturbance and the presence of plaque and spectral Doppler to measure flow velocities from the renal artery ostium to the hilum. Doppler spectral waveforms are obtained from the segmental arteries of the renal parenchyma. Kidney length is noted. Multiple renal arteries are noted. Patency of the renal veins and any other abnormalities such as masses or cysts are documented.

A review of common clinical scenarios where cerebrovascular ultrasound is used follows. These scenarios are scored for appropriate use on a scale of 1-9. A median score of 7-9 indicates that this is an appropriate test for the specific indication. A median score of 4-6 indicates that there is unclear evidence as to the appropriateness of the test. A median score of 1-3 indicates that the test is not generally acceptable for the indication.

Indications

This procedure is indicated in the evaluation and/or management of vascular disease involving vessels of the abdominal, pelvic, scrotal contents, and/or retroperitoneal organs.

Limitations

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.


Bill Type Codes:

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.

999x Not Applicable

Revenue Codes: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.


Group 1 Codes:

93975 Vascular study
93976 Vascular study
93978 Vascular study
93979 Vascular study
93980 Penile vascular study
93981 Penile vascular study

Billing and Coding Guidelines.

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.


IV. Visceral Vascular Studies (93975, 93976, 93978, 93979)


Indications:

This procedure is indicated in the evaluation and/or management of vascular disease involving vessels of the abdominal, pelvic, scrotal contents, and/or retroperitoneal organs.


Limitations:

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. Follow-up of an abdominal aneurysm on a periodic basis using abdominal ultrasound rather than visceral vascular studies to determine growth and potential need for intervention is allowed.

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. 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.



V. Hemodialysis Access Examination (93990)

Indications:

Medicare will consider separate payment for vascular studies (CPT code 93990) on symptomatic ESRD patients, when Doppler flow studies are used to provide diagnostic information to determine the appropriate medical intervention. Medicare considers a Doppler flow study medically necessary when the beneficiary’s dialysis access Printed on 11/11/2014. Page 8 of 35
• Elevated venous pressure > 200mm Hg on a 200 cc/min. pump;


• Elevated recirculation of time of 12% or greater, and

• Low urea reduction rate < 60%

• An access with a palpable "water hammer" pulse on examination (which implies venous outflow obstruction)



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




Connecticare Guidelines

93926 Lower extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93930 Upper extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a  radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93931 Upper extremity study Ultrasound General Non- advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that  would hit copay. Yes 93970

ULTRASOUND VENOUS DOPPLER

EXTREMETRIES Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93971 Extremity study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider.

These are sometimes billed with a related radiology code that would hit copay. Yes 93975 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93976 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes 93978 Vascular study Ultrasound General Non-advanced Vascular services, not radiology code but apply copay if done by a radiology/facility provider. These are sometimes billed with a related radiology code that would hit copay. Yes



Group 9 Paragraph: Visceral Vascular Studies (93975, 93976, 93978, 93979)

Use ICD-9 codes 401.0, 403.00, 403.01, and 405.01 to report accelerated hypertension.

Use ICD-9 code 456.8 for gastric varices.

Use ICD-9 code 785.9 to report an abdominal bruit.


LMRP Description

Duplex scanning describes an ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging.

Indications and Limitations of Coverage and/ or Medical Necessity

Arterial inflow and venous outflow of abdominal, pelvic, and/or retroperitoneal organs (procedure codes 93975 and 93976)

Florida Medicare may provide coverage for duplex scanning of arterial inflow and venous outflow of abdominal, pelvic, and/or retroperitoneal organs when performed for the following indications:

• To evaluate patients presenting with signs or symptoms such as epigastric or periumbilical postprandial pains that last for 1-3 hours and/or with associated weight loss resulting from decreased oral intake which may indicate chronic intestinal ischemia.

• To evaluate patients presenting with an acute onset of crampy or steady epigastric and periumbilical abdominal pain combined with minimal or no findings on abdominal examination and a high leukocyte count to rule out acute intestinal ischemia.

• To evaluate a patient who has sustained trauma to the abdominal, pelvic and/or retroperitoneal area resulting in a possible injury to the arterial inflow and/or venous outflow of the abdominal, pelvic and/or retroperitoneal organs.

• To evaluate a suspicion of an aneurysm of the renal artery or other visceral artery based on a patients signs and symptoms of abdominal pain or noted as an incidental finding on another radiological examination.

• To evaluate a hypertensive patient who has failed first line antihypertensive drug therapy in order to rule out renovascular disease such as renal artery stenosis, renal arteriovenous fistula, or renal aneurysm as a cause for the uncontrolled hypertension.

• To evaluate a patient with signs and symptoms of portal hypertension. These may include abdominaldiscomfort and distention, abdominal collaterals (caput medusae), abdominal bruit, ascites, encephalopathy, esophageal varices, splenomegaly, etc.

• To evaluate patients suspected of an embolism, thrombosis, hemorrhage or infarction of the portal vein, renal vein and/or renal artery. These patients may present with many different symptoms such as abdominal discomfort, hematuria, cardiac failure, diastolic hypertension, jaundice, fatigue, weakness, malaise, etc.

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

• To 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.

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

• To 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 necks and arms, distended neck veins).

• To 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.

• To 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, asymmetric diminution of arterial pulses and systolic bruits over the areas where the aortic lumen is narrowed.

• Initial evaluation of a patient presenting with signs and symptoms such as intermittent claudication in the calf muscles, thighs and/or buttocks, rest pain, weakness in legs or feeling of tiredness in the buttocks, etc. which may suggest occlusive disease of the aorta and iliac arteries. The physical examination usually reveals decreased or absent femoral pulses, a bruit over the narrowed artery, and possibly muscle atrophy. If severe occlusive disease exists, the patient will have atrophic changes of the skin, thick nails, coolness of the skin with pallor and cyanosis.

• To evaluate patients suspected of an abdominal or thoracic arterial embolism or thrombosis. These patients usually present with severe pain in one or both lower extremities, numbness, and symmetric weakness of the legs, with absent or severely reduced pulses below the embolism site.

• To evaluate patients presenting with complaints of pain in the calf or thigh, slight swelling in the involved leg, tenderness of the iliac vein, etc. which may suggest phlebitis or thrombophlebitis of the iliac vein or inferior vena cava.
• To evaluate a patient who has sustained trauma to thechest wall and/or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

• To assess the continued patency of both native venous and prosthetic arterial grafts following surgical intervention. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

• To monitor the sites of various percutaneous interventions, including, but not limited to angioplasty, thrombolysis/thrombectomy, atherectomy, or stent placement. Usually this is performed at 6 weeks, 3 months, then every six (6) months.

Note: Duplex testing should be reserved for specific indications for which the precise anatomic information obtained by this technique is likely to be useful.

Therefore, it would be rare to see duplex scanning being performed for conditions in which another diagnostic test is recommended (e.g., an aortic dissection is better diagnosed with a chest X-ray, transesophageal echocardiogram or aortography)

CPT/HCPCS Section & Benefit Category

Non-invasive Vascular Diagnostic Studies/Medicine

CPT/HCPCS Codes 93975 93976 93978 93979

ICD-10 CODE DESCRIPTION

C56.1 - C57.4 - Opens in a new window Malignant neoplasm of right ovary - Malignant neoplasm of uterine adnexa, unspecified
C62.00 - C62.92 - Opens in a new window Malignant neoplasm of unspecified undescended testis - Malignant neoplasm of left testis, unspecified whether descended or undescended
D27.0 - D27.9 - Opens in a new window Benign neoplasm of right ovary - Benign neoplasm of unspecified ovary
I10 - I11.0 - Opens in a new window Essential (primary) hypertension - Hypertensive heart disease with heart failure
I12.0 - I15.1 - Opens in a new window Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease - Hypertension secondary to other renal disorders
I15.8 Other secondary hypertension
I70.0 - I70.1 - Opens in a new window Atherosclerosis of aorta - Atherosclerosis of renal artery
I70.90 - I70.91 - Opens in a new window Unspecified atherosclerosis - Generalized atherosclerosis
I71.00 - I71.9 - Opens in a new window Dissection of unspecified site of aorta - Aortic aneurysm of unspecified site, without rupture
I72.2 - I72.8 - Opens in a new window Aneurysm of renal artery - Aneurysm of other specified arteries
I74.01 - I74.19 - Opens in a new window Saddle embolus of abdominal aorta - Embolism and thrombosis of other parts of aorta
I74.5 Embolism and thrombosis of iliac artery
I75.81 Atheroembolism of kidney
I76 Septic arterial embolism
I77.4 Celiac artery compression syndrome
I77.72 - I77.73 - Opens in a new window Dissection of iliac artery - Dissection of renal artery
I77.810 - I77.819 - Opens in a new window Thoracic aortic ectasia - Aortic ectasia, unspecified site
I79.0 Aneurysm of aorta in diseases classified elsewhere
I80.211 - I80.219 - Opens in a new window Phlebitis and thrombophlebitis of right iliac vein - Phlebitis and thrombophlebitis of unspecified iliac vein
I81 - I82.1 - Opens in a new window Portal vein thrombosis - Thrombophlebitis migrans
I82.220 - I82.221 - Opens in a new window Acute embolism and thrombosis of inferior vena cava - Chronic embolism and thrombosis of inferior vena cava
I82.3 Embolism and thrombosis of renal vein
I85.00 - I85.01 - Opens in a new window Esophageal varices without bleeding - Esophageal varices with bleeding
I86.1 - I86.3 - Opens in a new window Scrotal varices - Vulval varices
I87.1 Compression of vein
K55.8 - K55.9 - Opens in a new window Other vascular disorders of intestine - Vascular disorder of intestine, unspecified
K70.2 - K70.31 - Opens in a new window Alcoholic fibrosis and sclerosis of liver - Alcoholic cirrhosis of liver with ascites
K72.00 - K72.91 - Opens in a new window Acute and subacute hepatic failure without coma - Hepatic failure, unspecified with coma
K74.0 Hepatic fibrosis
K74.60 - K74.69 - Opens in a new window Unspecified cirrhosis of liver - Other cirrhosis of liver
K75.1 Phlebitis of portal vein
K75.81 Nonalcoholic steatohepatitis (NASH)
K76.0 Fatty (change of) liver, not elsewhere classified
K76.2 Central hemorrhagic necrosis of liver
K76.6 Portal hypertension
K76.89 Other specified diseases of liver
M30.0 - M31.7 - Opens in a new window Polyarteritis nodosa - Microscopic polyangiitis
M54.5 Low back pain
N17.0 - N17.9 - Opens in a new window Acute kidney failure with tubular necrosis - Acute kidney failure, unspecified
N26.2 Page kidney
N27.0 - N27.1 - Opens in a new window Small kidney, unilateral - Small kidney, bilateral
N28.0 Ischemia and infarction of kidney
N44.00 - N44.04 - Opens in a new window Torsion of testis, unspecified - Torsion of appendix epididymis
N45.1 - N45.4 - Opens in a new window Epididymitis - Abscess of epididymis or testis
N48.30 - N48.39 - Opens in a new window Priapism, unspecified - Other priapism
N50.1 Vascular disorders of male genital organs
N50.9 - N51 - Opens in a new window Disorder of male genital organs, unspecified - Disorders of male genital organs in diseases classified elsewhere
N94.89 Other specified conditions associated with female genital organs and menstrual cycle
R09.89 - R10.33 - Opens in a new window Other specified symptoms and signs involving the circulatory and respiratory systems - Periumbilical pain
R10.83 - R10.9 - Opens in a new window Colic - Unspecified abdominal pain
R18.0 - R18.8 - Opens in a new window Malignant ascites - Other ascites
R19.01 - R19.09 - Opens in a new window Right upper quadrant abdominal swelling, mass and lump - Other intra-abdominal and pelvic swelling, mass and lump
S25.00XA - S25.09XS - Opens in a new window Unspecified injury of thoracic aorta, initial encounter - Other specified injury of thoracic aorta, sequela
S35.00XA - S35.8X9S - Opens in a new window Unspecified injury of abdominal aorta, initial encounter - Unspecified injury of other blood vessels at abdomen, lower back and pelvis level, sequela
Z95.820 - Z95.828 - Opens in a new window Peripheral vascular angioplasty status with implants and grafts - Presence of other vascular implants and grafts
Showing 1 to 55 of 55 entries in Group 1
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Function-related G-codes G8978, g9186 ,g9158

E. Function-related G-codes

There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets are generally for PT and OT functional limitations and eight sets of G-codes are for SLP functional limitations.

The following G-codes are for functional limitations typically seen in beneficiaries receiving PT or OT services. The first four of these sets describe categories of functional limitations and the final two sets describe “other” functional limitations, which are to be used for functional limitations not described by one of the four categories.



NONPAYABLE G-CODES FOR FUNCTIONAL LIMITATIONS

Code            Long Descriptor           Short Descriptor

Mobility G-code Set

G8978
Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
Mobility current status


G8979
Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Mobility goal status



G8980
Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting
Mobility D/C status
Changing & Maintaining Body Position G-code Set


G8981
Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals
Body pos current status


G8982
Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Body pos goal status



G8983
Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting
Body pos D/C status
Carrying, Moving & Handling Objects G-code Set



G8984
Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals
Carry current status


G8985
Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Carry goal status



G8986
Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting
Carry D/C status
Self Care G-code Set


G8987
Self care functional limitation, current status, at therapy episode outset and at reporting intervals
Self care current status


G8988
Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Self care goal status


G8989
Self care functional limitation, discharge status, at discharge from therapy or to end reporting
Self care D/C status



The following “other PT/OT” functional G-codes are used to report:

• a beneficiary’s functional limitation that is not defined by one of the above four categories;

• a beneficiary whose therapy services are not intended to treat a functional limitation;

• or a beneficiary’s functional limitation when an overall, composite or other score from a functional assessment too is used and it does not clearly represent a functional limitation defined by one of the above four code sets.




Code               Long Descriptor            Short Descriptor

Other PT/OT Primary G-code Set


G8990
Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals
Other PT/OT current status


G8991
Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Other PT/OT goal status



G8992
Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting
Other PT/OT D/C status




Other PT/OT Subsequent G-code Set

G8993
Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals
Sub PT/OT current status



G8994
Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Sub PT/OT goal status




The following G-codes are for functional limitations typically seen in beneficiaries receiving SLP services. Seven are for specific functional communication measures, which are modeled after the National Outcomes Measurement System (NOMS), and one is for any “other” measure not described by one of the other seven.


Code             Long Descriptor              Short Descriptor

Swallowing G-code Set

G8996
Swallowing functional limitation, current status, at therapy episode outset and at reporting intervals
Swallow current status



G8997
Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Swallow goal status


G8998
Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting
Swallow D/C status




Motor Speech G-code Set
(Note: These codes are not sequentially numbered)


G8999
Motor speech functional limitation, current status, at therapy episode outset and at reporting intervals
Motor speech current status



G9186
Motor speech functional limitation, projected goal status at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Motor speech goal status



G9158
Motor speech functional limitation, discharge status, at discharge from therapy or to end reporting
Motor speech D/C status




Spoken Language Comprehension G-code Set

G9159
Spoken language comprehension functional limitation, current status, at therapy episode outset and at reporting intervals
Lang comp current status


G9160
Spoken language comprehension functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Lang comp goal status


G9161
Spoken language comprehension functional limitation, discharge status, at discharge from therapy or to end reporting
Lang comp D/C status





Spoken Language Expressive G-code Set

G9162
Spoken language expression functional limitation, current status, at therapy episode outset and at reporting intervals
Lang express current status


G9163
Spoken language expression functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Lang press goal status



G9164
Spoken language expression functional limitation, discharge status, at discharge from therapy or to end reporting
Lang express D/C status




Attention G-code Set

G9165
Attention functional limitation, current status, at therapy episode outset and at reporting intervals
Atten current status


G9166
Attention functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Atten goal status



Code              Long Descriptor                     Short Descriptor


G9167
Attention functional limitation, discharge status, at discharge from therapy or to end reporting
Atten D/C status


Memory G-code Set

G9168
Memory functional limitation, current status, at therapy episode outset and at reporting intervals
Memory current status



G9169
Memory functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Memory goal status



G9170
Memory functional limitation, discharge status, at discharge from therapy or to end reporting
Memory D/C status
Voice G-code Set


G9171
Voice functional limitation, current status, at therapy episode outset and at reporting intervals
Voice current status



G9172
Voice functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Voice goal status



G9173
Voice functional limitation, discharge status, at discharge from therapy or to end reporting
Voice D/C status



The following “other SLP” G-code set is used to report:

• on one of the other eight NOMS-defined functional measures not described by the above code sets; or

• to report an overall, composite or other score from assessment tool that does not clearly represent one of the above seven categorical SLP functional measures.




Code            Long Descriptor            Short Descriptor


Other Speech Language Pathology G-code Set

G9174
Other speech language pathology functional limitation, current status, at therapy episode outset and at reporting intervals
Speech lang current status



G9175
Other speech language pathology functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Speech lang goal status



G9176
Other speech language pathology functional limitation, discharge status, at discharge from therapy or to end reporting
Speech lang D/C status

CPT code 92928, 92941 AND c9600 - Percutaneous transcatheter

Billing for Intracoronary Stent Placement


Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug-eluting or drug-eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Intracoronary Drug-Eluting Stents), respectively). In order to effectuate this policy, we created HCPCS G-codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug-eluting intracoronary stent placement procedures that parallel existing Procedure  codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug-eluting intracoronary stent placement procedures. For CY 2012 and years prior, Procedure  codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.

Effective January 1, 2013, the AMA’s Procedure  Editorial Panel is deleting Procedure  codes 92980 and 92981 and replacing them with the following new Procedure  codes:

• Procedure  code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)

• Procedure  code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• Procedure  code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);

• Procedure  code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• Procedure  code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);

• Procedure  code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));

• Procedure  code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);

• Procedure  code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel); and

• Procedure  code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).

In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug-eluting and drug-eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C-codes to parallel the new Procedure  codes:

• HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);

• HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));

• HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);

• HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));

• HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);

• HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; single vessel); and

• HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).

Procedure  codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug-eluting intracoronary stent placement procedures and are assigned to APC 0104. HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.


Transitional Corridor Payments

The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit provider’s losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.

Section 405 of BIPA provides that children’s hospitals described in §1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000. Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below. Contractors determine TOPs eligibility and calculate interim TOPs.

Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC. The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data. TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.

Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC. They are:

• The provider number;

• Fiscal year begin date;

• The provider type;

• Actual geographic location - CBSA (from the IPSF);

• Wage index location - CBSA (from the IPSF); and

• Bed size (from the IPSF)

Pursuant to §403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost report for the cost reporting period ending in calendar year 1996. The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment-to-cost ratio used in calculating a TOP will be based on the hospital’s first cost report for a period ending after calendar year 1996 and before calendar year 2001. This provision is effective retroactively to August 1, 2000.

Future updates will be issued in a Recurring Update Notification.

Coverage Indications, Limitations, and/or Medical Necessity

Overview

Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty or simply angioplasty, is a non-surgical procedure used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease. These stenotic segments are due to the buildup of the cholesterol-laden plaques that form due to atherosclerosis. During PCI, a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. A stent is often placed at the site of blockage to permanently open the artery.

Percutaneous transluminal coronary angioplasty (PTCA) is a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.

Indications:

Percutaneous coronary intervention (PCI) may be indicated in the management of patients with:
acute coronary syndrome (e.g. acute myocardial infarction, unstable angina)

a history of significant obstructive atherosclerotic disease

restenosis of a coronary artery previously treated with intracoronary stent or other revascularization procedure

chronic angina

silent ischemia


Intracoronary ultrasound (IVUS) may be separately covered when needed to assess the extent of coronary stenosis if equivocal on angiography, or when needed to assess the patency and integrity of a coronary artery during percutaneous coronary intervention. Alternatively, intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement may be performed to assess the degree of stenosis within a vessel. Intracoronary ultrasound or fractional flow reserve measurement should be performed on an individual artery as clinically indicated. Both procedures are not considered medically necessary unless written documentation is submitted to support medical necessity. Intracoronary ultrasound and Doppler fractional flow reserve studies can be required in multivessel coronary artery disease (CAD).

A diagnostic cardiac catheterization to assess the nature of the lesion(s) prior to the intervention is a covered service. The diagnostic cardiac catheterization may be performed at any time prior to the PCI, including the same day as the PCI. Performance of a diagnostic cardiac catheterization and interventional procedure on the same day is increasingly the standard of practice. If the diagnostic catheterization is done within 30 days of the PCI, it is usually not necessary to repeat the catheterization unless there is a documented change in the patient’s condition. While there may be reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center, excessive dye load, further treatment planning or evaluation of angiography, etc.), it is recommended that both procedures be performed during the same encounter when medically appropriate, with detailed discussion of benefits and risks of PCI. Separation of these procedures for the purpose of circumventing the multiple surgery pricing, or for the convenience of physician or hospital scheduling, is considered an inappropriate practice and may subject the services to review and denial for medical necessity. The decision to stage these procedures is deferred to the judgment of the interventional cardiologist, and individualized only to the clinical needs of the patient. (e.g., dye load already received; need to correlate findings with other test results, etc.). Reasons for delaying an indicated percutaneous coronary intervention should be documented in the medical record. Unless there is a new clinical event, a change in symptomatology, abnormal examination or other test results, a repeat diagnostic catheterization within three months of the last diagnostic catheterization and prior to the percutaneous coronary intervention is generally not reimbursable and is considered not reasonable and necessary.

Limitations: 

Generally PCI is not indicated for:
Patients that can be managed medically.

Right heart catheterization and insertion of a Swan - Ganz catheter are not generally medically necessary for a PCI and will be denied, unless medically necessary when performed incident to a diagnostic catheterization prior to the intervention.

Standby services of a surgeon or anesthesiologist are not covered services.

Patient with stable CAD.

ICD-10 Codes that may support medical necessity (for dates of service on or after October 1, 2015): Drug-eluting Stents for Ischemic Heart Disease

I20.0 - I20.9 Angina pectoris
I21.01 – I21.4 ST elevation (STEMI) and non-ST elevation (NSTEMI)
myocardial infarction
I22.0 – I22.9 Subsequent ST elevation (STEMI) and non-ST elevation
(NSTEMI) myocardial infarction
I24.0 - I24.9 Other acute ischemic heart diseases
I25.10 – I25.119 Atherosclerotic heart disease of native coronary artery with or
without angina pectoris
I25.5 Ischemic cardiomyopathy
I25.6 Silent myocardial ischemia
I25.700 – I25.799 Atherosclerosis of coronary artery bypass graft(s) and coronary
artery of transplanted heart with angina pectoris
I25.810 – I25.89 Other forms of chronic ischemic heart disease
I25.9 Chronic ischemic heart disease, unspecified
T82.817A - T82.817S Embolism of cardiac prosthetic devices, implants and grafts
T82.827A - T82.827S Fibrosis of cardiac prosthetic devices, implants and grafts
T82.837A - T82.837S Hemorrhage of cardiac prosthetic devices, implants and grafts
T82.847A - T82.847S Pain from cardiac prosthetic devices, implants and grafts
T82.857A - T82.857S Stenosis of cardiac prosthetic devices, implants and grafts
T82.867A - T82.867S Thrombosis of cardiac prosthetic devices, implants and grafts
T82.897A - T82.897S Other specified complication of cardiac prosthetic devices,
implants and grafts
T82.9xxA - T82.9xxS Unspecified complication of cardiac and vascular prosthetic
device, implant and graft
36.07:
Insertion of drug-eluting coronary
artery stent(s)
00.66:
Percutaneous transluminal
coronary angioplasty
17.55
Transluminal coronary
atherectomy
Code Also
00.40:
Procedure on single vessel
00.41:
Procedure on two vessels
00.42:
Procedure on three vessels
00.43:
Procedure on four or more
vessels
00.44:
Procedure on vessel/bifurcation
00.45:
Insertion of one vascular stent
00.46:
Insertion of two vascular stents
00.47:
Insertion of three vascular stents
00.48:
Insertion of four or more vascular stent

00.24:
Intravascular imaging of coronary
vessels
00.28:
Intravascular imaging, other
specified vessel(s)
00.29:
Intravascular imaging unspecified
vessel(s)

CPT 43775, 43644 - Laparoscopy Bariatric Surgery

Covered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are covered for bariatric surgery:

43770 - Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).

43644 - Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less).

43645 - Laparoscopy with gastric bypass and small intestine reconstruction to limit absorption. (Do not report 43645 in conjunction with 49320, 43847.)

43845 - Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy and ileoieostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch).

43846 - Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less Roux-en-Y gastroenterostomy. (For greater than 150 cm, use 43847.) (For laparoscopic procedure, use 43644.)

43847 - With small intestine reconstruction to limit absorption.

43775- Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) (Effective June 27, 2012, covered at contractor’s discretion.)

Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity

Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity. The patient must have a body-mass index (BMI) =35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. This medical information must be documented in the patient's medical record. In addition, the procedure must be performed at an approved facility. A list of approved facilities may be found at http://www.cms.gov/Medicare/Medicare-General-Information/MedicareApprovedFacilitie/Bariatric-Surgery.html
Effective for services performed on and after February 12, 2009, Medicare has determined that Type 2 diabetes mellitus is a co-morbidity for purposes of processing bariatric surgery claims.

Effective for dates of service on and after September 24, 2013, the Centers for Medicare & Medicaid Services (CMS) has removed the certified facility requirements for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.

Please note the additional national coverage determinations related to bariatric surgery will be consolidated and subsumed into Publication 100-03, Chapter 1, section 100.1. These include sections 40.5, 100.8, 100.11 and 100.14.

Open Roux-en-Y gastric bypass (RYGBP)

Laparoscopic Roux-en-Y gastric bypass (RYGBP)

Laparoscopic adjustable gastric banding (LAGB)

Open biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)

Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or gastric reduction duodenal switch (BPD/GRDS)

Laparoscopic sleeve gastrectomy (LSG) (Effective June 27, 2012, covered at Medicare Administrative Contractor (MAC) discretion.

Non-Covered HCPCS Procedure Codes

For services on or after February 21, 2006, the following HCPCS procedure codes are non-covered for bariatric surgery:

43842 - Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical banded gastroplasty 

NOC code 43999 used to bill for:

Laparoscopic vertical banded gastroplasty

Open sleeve gastrectomy

Laparoscopic sleeve gastrectomy (for contractor non-covered instances)

Open adjustable gastric banding

Covered ICD Procedure Codes

For services on or after February 21, 2006, the following independent ICD-9/ICD-10 procedure codes are covered for bariatric surgery:

44.38 - Laparoscopic gastroenterostomy (laparoscopic Roux-en-Y), or

0D16479

Bypass Stomach to Duodenum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D1647A

Bypass Stomach to Jejunum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D1647B

Bypass Stomach to Ileum with Autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D1647L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D164J9

Bypass Stomach to Duodenum with Synthetic Substitute, Percutaneous Endoscopic Approach

0D164JA

Bypass Stomach to Jejunum with Synthetic Substitute, Percutaneous Endoscopic Approach

0D164JB

Bypass Stomach to Ileum with Synthetic Substitute, Percutaneous Endoscopic Approach

0D164JL

Bypass Stomach to Transverse Colon with Synthetic Substitute, Percutaneous Endoscopic Approach

0D164K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D164KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D164KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D164KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue Substitute, Percutaneous Endoscopic Approach

0D164Z9

Bypass Stomach to Duodenum, Percutaneous Endoscopic Approach

0D164ZA

Bypass Stomach to Jejunum, Percutaneous Endoscopic Approach

0D164ZB

Bypass Stomach to Ileum, Percutaneous Endoscopic Approach

0D164ZL

Bypass Stomach to Transverse Colon, Percutaneous Endoscopic Approach

44.39 - Other gastroenterostomy (open Roux-en-Y), or

0D16079

Bypass Stomach to Duodenum with Autologous Tissue Substitute, Open Approach

0D1607A

Bypass Stomach to Jejunum with Autologous Tissue Substitute, Open Approach

0D1607B

Bypass Stomach to Ileum with Autologous Tissue Substitute, Open Approach

0D1607L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Open Approach

0D160J9

Bypass Stomach to Duodenum with Synthetic Substitute, Open Approach

0D160JA

Bypass Stomach to Jejunum with Synthetic Substitute, Open Approach

0D160JB

Bypass Stomach to Ileum with Synthetic Substitute, Open Approach

0D160JL

Bypass Stomach to Transverse Colon with Synthetic Substitute, Open Approach

0D160K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Open Approach

0D160KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Open Approach

0D160KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Open Approach

0D160KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue Substitute, Open Approach

0D160Z9

Bypass Stomach to Duodenum, Open Approach

0D160ZA

Bypass Stomach to Jejunum, Open Approach

0D160ZB

Bypass Stomach to Ileum, Open Approach

0D160ZL

Bypass Stomach to Transverse Colon, Open Approach

0D16879

Bypass Stomach to Duodenum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D1687A

Bypass Stomach to Jejunum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D1687B

Bypass Stomach to Ileum with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D1687L

Bypass Stomach to Transverse Colon with Autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D168J9

Bypass Stomach to Duodenum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic

0D168JA

Bypass Stomach to Jejunum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic

0D168JB

Bypass Stomach to Ileum with Synthetic Substitute, Via Natural or Artificial Opening Endoscopic

0D168JL

Bypass Stomach to Transverse Colon with Synthetic Substitute, Via

Natural or Artificial Opening Endoscopic

0D168K9

Bypass Stomach to Duodenum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D168KA

Bypass Stomach to Jejunum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D168KB

Bypass Stomach to Ileum with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D168KL

Bypass Stomach to Transverse Colon with Non-autologous Tissue Substitute, Via Natural or Artificial Opening Endoscopic

0D168Z9

Bypass Stomach to Duodenum, Via Natural or Artificial Opening Endoscopic

0D168ZA

Bypass Stomach to Jejunum, Via Natural or Artificial Opening Endoscopic

0D168ZB

Bypass Stomach to Ileum, Via Natural or Artificial Opening Endoscopic

0D168ZL

Bypass Stomach to Transverse Colon, Via Natural or Artificial Opening Endoscopic

44.95 - Laparoscopic gastric restrictive procedure (laparoscopic adjustable gastric band and port insertion), or 0DV64CZ – Restriction of Stomach with Extraluminal Device, Percutaneous Endoscopic Approach

Many more

Claims Guidance for Payment


Covered Bariatric Surgery Procedures for Treatment of Co-Morbid Conditions Related to Morbid Obesity

Contractors shall process covered bariatric surgery claims as follows:

1. Identify bariatric surgery claims.

Contractors identify inpatient bariatric surgery claims by the presence of ICD-9/ICD-10 diagnosis code 278.01/E66.01as the primary diagnosis (for morbid obesity) and one of the covered ICD-9/ICD-10 procedure codes listed in §150.3.

Contractors identify practitioner bariatric surgery claims by the presence of ICD-9/ICD-10 diagnosis code 278.01/E66.01 as the primary diagnosis (for morbid obesity) and one of the covered HCPCS procedure codes listed in §150.2.

2. Perform facility certification validation for all bariatric surgery claims on a pre-pay basis up to and including date of service September 23, 2013.

A list of approved facilities are found at the link noted in section 150.1, section A, above.

3. Review bariatric surgery claims data and determine whether a pre- or post-pay sample of bariatric surgery claims need further review to assure that the beneficiary has a BMI =35 (V85.35-V85.45/Z68.35-Z68.45) (see ICD-10 equivalents above in section 150.5), and at least one co-morbidity related to obesity

The A/B MAC medical director may define the appropriate method for addressing the obesity-related co-morbid requirement.

Effective for dates of service on and after September 24, 2013, CMS has removed the certified facility requirements for Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity.

CPT code G0248, G0249, G0250 - Demonstrate use home

HCPCS for Carriers

For services furnished on or after July 1, 2002, and prior to March 19, 2008, the applicable HCPCS codes for this benefit are:

G0248: Demonstration, at initial use, of home INR monitoring for patient with mechanical heart valve(s) who meets Medicare coverage criteria, under the direction of a physician; includes: demonstration use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results and documentation of a patient’s ability to perform testing.


G0249: Provision of test materials and equipment for home INR monitoring to patient with mechanical heart valve(s) who meets Medicare coverage criteria. Includes provision of materials for use in the home and reporting of test results to physician; per 4 tests.


G0250: Physician review; interpretation and patient management of home INR testing for a patient with mechanical heart valve(s) who meets other coverage criteria; per 4 tests (does not require face-to-face).


Home prothrombin time (PT/INR) monitoring Choosing correct DOS

There are three procedure codes applicable to this service.

1. G0248 -- instructions for use of the INR monitor
The DOS is the date the instructions are given in a face-to-face setting with the patient.

2. G0249 -- supplies along with the monitor
The DOS is the date the supplies and monitor are given to the patient.

3. G0250 -- physician interpretation of the test results and face-to-face verification that the patient is using the device.

This service is payable only once every four weeks. The DOS is the date of the fourth test interpretations.

Coverage and Billing for Home Prothrombin Time (PT/INR) Monitoring for Home Anticoagulation Management

The prothrombin time (PT) test is an in-vitro test to assess coagulation. PT testing and its normalized correlate, the International Normalized Ratio (INR), are the standard measurements for therapeutic effectiveness of warfarin therapy. Warfarin, Coumadin®, and others, are self-administered, oral anticoagulant, or blood thinner, medications that affect a person’s Vitamin K-dependent clotting factors.

Use of the INR allows physicians to determine the level of anticoagulation in a patient independent of the laboratory reagents used. The INR is the ratio of the patient's prothrombin time compared to the mean prothrombin time for a group of normal individuals.


Coverage Requirements

For services furnished on or after July 1, 2002, Medicare will cover the use of home INR monitoring for anticoagulation management for patients with mechanical heart valves on warfarin. The monitor and the home testing must be prescribed by a physician and the following patient requirements must be met:

• Must have been anticoagulated for at least 3 months prior to use of the home INR device;

• Must undergo an educational program on anticoagulation management and the use of the device prior to its use in the home; and

• Self testing with the device is limited to a frequency of once per week.

For services furnished on or after March 19, 2008, the Centers for Medicare & Medicaid Services revised its national coverage determination (NCD) on PT/INR Monitoring for Home Anticoagulation Management as follows:

Medicare will cover the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following requirements must be met:

1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,

2. The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,

3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,

4. Self-testing with the device should not occur more frequently than once a week.


NOTE: Porcine valves are not included in this NCD, so Medicare will not make payment on home INR monitoring for patients with porcine valves unless covered by local Medicare contractors.

ICD-10-CM Code              Code Description

D68.51

Activated protein C resistanc

D68.52

Prothrombin gene mutation

D68.59

Other primary thrombophilia

D68.61

Antiphospholipid syndrome

D68.62

Lupus anticoagulant syndrome



Phlebitis & Thrombophlebitis

ICD-10-CM Code             Code Description

I80.00

Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

I80.01

Phlebitis and thrombophlebitis of superficial vessels of right lower extremity

I80.02

Phlebitis and thrombophlebitis of superficial vessels of left lower extremity

I80.03

Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral

I80.10

Phlebitis and thrombophlebitis of unspecified femoral vein

I80.11

Phlebitis and thrombophlebitis of right femoral vein

I80.12

Phlebitis and thrombophlebitis of left femoral vein

I80.13

Phlebitis and thrombophlebitis of femoral vein, bilateral

I80.201

Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity

I80.202

Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity

I80.203

Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral

I80.209

Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity

I80.221

Phlebitis and thrombophlebitis of right popliteal vein

I80.222

Phlebitis and thrombophlebitis of left popliteal vein

I80.223

Phlebitis and thrombophlebitis of popliteal vein, bilateral

I80.229

Phlebitis and thrombophlebitis of unspecified popliteal vein

I80.231

Phlebitis and thrombophlebitis of right tibial vein

I80.232

Phlebitis and thrombophlebitis of left tibial vein

I80.233

Phlebitis and thrombophlebitis of tibial vein, bilateral

I80.239

Phlebitis and thrombophlebitis of unspecified tibial vein

I80.291

Phlebitis and thrombophlebitis of other deep vessels of right lower extremity

I80.292

Phlebitis and thrombophlebitis of other deep vessels of left lower extremity

I80.293

Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral

I80.299

Phlebitis and thrombophlebitis of other deep vessels of unspecified lower extremity

I80.3

Phlebitis and thrombophlebitis of lower extremities, unspecified

I80.211

Phlebitis and thrombophlebitis of right iliac vein

I80.212

Phlebitis and thrombophlebitis of left iliac vein

I80.213

Phlebitis and thrombophlebitis of iliac vein, bilateral

I80.219

Phlebitis and thrombophlebitis of unspecified iliac vein

I80.8

Phlebitis and thrombophlebitis of other sites

I80.9

Phlebitis and thrombophlebitis of unspecified site


Other Venous Embolism & Thrombosis

ICD-10-CM Code  Code Description

I82.0

Budd- Chiari syndrome

I82.1

Thrombophlebitis migrans

I82.211

Chronic embolism and thrombosis of superior vena cava

I82220

Acute embolism and thrombosis of inferior vena cava

I82.221

Chronic embolism and thrombosis of inferior vena cava

I82.291

Chronic embolism and thrombosis of other thoracic veins

I82.3

Ultrasonic cpt 76942 - knee injection billing

CPT CODE 76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation -average fee payment - $60 - $70

Ultrasonic Guidance for Knee Injections

Audits were recently performed by Highmark Medicare Services’ Medical Review Department for procedure code 76942, ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

In reviewing the medical records provided to support these services, it was determined that providers were using ultrasound guidance for knee joint injections. The documentation did not provide any information which would support the medical necessity for using ultrasound guidance for knee injections.

Medical necessity is defined as the need for an item(s) or service(s), to be reasonable and necessary for the diagnosis or treatment of disease, injury or defect. The need for the item or service must be clearly documented in the patient’s medical record.

To report the use of ultrasound to guide injections or aspirations, the suggested code is 76942 - Ultrasonic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Report 76942 in addition to the code for the underlying procedure.

Under the National Correct Coding Initiative, NCCI, which sets CMS payment policy as well as many private payers, one unit of service is allowed for CPT code 76942 in a single patient encounter regardless of the number of needle placements performed. Per NCCI, “The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.


Medically necessary services or items are:

• Appropriate for the symptoms and diagnosis or treatment of the patient’s condition, illness, disease or injury; and
• Provided for the diagnosis or the direct care of the patient’s condition, illness, disease or injury; and
• In accordance with current standards of good medical practice; and
• Not primarily for the convenience of the patient or provider; and
• The most appropriate supply or level of service that can be safely provided to the patient.
The use of ultrasound guidance for knee joint injections may be considered medically reasonable and necessary by Highmark Medicare Services if the documentation supports one of the following:
• The failure of the initial attempt at the knee joint injection where the provider is unable to aspirate any fluid.
• The size of the patient’s knee(s), due to morbid obesity or disease process, inhibits the provider’s ability to inject the knee(s) without ultrasound guidance.
• The provider is planning to drain a popliteal (Baker’s) cyst.

Although there is data to support that ultrasound guidance improves the accuracy of knee joint injections and reduces procedural pain in some cases, the data does not support improved clinical outcomes to support the coverage of ultrasound guidance for all knee joint injections. In addition, package inserts for drugs used for knee joint injections do not indicate the necessity of the use of ultrasound guidance for safe and effective usage.

Therefore, unless there is documentation provided to support the medical necessity for the ultrasound guidance for knee joint injections, the ultrasound guidance may be denied as coverage and reimbursement of healthcare services provided to Medicare beneficiaries requires that services be medically necessary in order to be eligible for reimbursement.


Billing and coding procedure code 76942


Based upon further input, First Coast Service Options Inc. (First Coast), the Medicare administrative contractor (MAC) for jurisdiction 9 (J9) is retracting previous articles titled Ultrasound guidance for needle placement in the office setting and Minimum criteria for reimbursement of diagnostic ultrasound tests. In the 2014 proposed rule for Revisions to Payment Policies under the Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) proposes a reduction in the relative value units (RVUs) based on equipment inputs and procedure time assumptions for Current Procedural Terminology (CPT®) code 76942 (Ultrasound guidance for needle placement [eg, biopsy, aspiration, injection, localization device], imaging supervision and interpretation). First Coast’s prior guidance and recoding of 76942 to an unlisted procedure code has been rescinded and claim adjustments will be performed. However, services that were previously denied as not reasonable and necessary for an ultrasound guidance service will remain denied.


Based upon clinical literature and input from practicing physicians in several specialties, MAC J9 maintains that ultrasound guidance may not be reasonable and necessary and is not the established standard of care for all needle placement procedures. Therefore, billing and coding the ultrasound guidance procedure code 76942 with an associated procedure must be clearly supported in the medical record as meeting the reasonable and necessary threshold for coverage for the given beneficiary or it should not be coded and submitted with the claim. On audit, if the documentation does not support that the ultrasound guidance provided clinical value, the claim will be denied. Providers should also be aware of MAC J9 local coverage determinations (LCDs) which specifically non-cover or limit coverage of ultrasound guidance for specific injection procedures. For example, LCD L29298 (Florida) and LCD L29403 (Puerto Rico and U.S. Virgin Islands) - Treatment of varicose veins of the lower extremity, specifically state under Limitations “Intraoperative ultrasound guidance is not separately reimbursable,” and in the Coding Guidelines the LCD states “Procedure code 76942 represents a service that is not covered by Medicare for the purposes of this LCD.” Another LCD providers should be aware of is L29307 (Florida) / L29408 (Puerto Rico and U.S. Virgin Islands) - Viscosupplementation therapy for knee. This LCD specifically states under Limitations that “Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patient’s affected knee on the day of the procedure makes needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will be covered.”

It is not expected that a non-physician practitioner (NPP) would perform procedures utilizing 76942 as they are not qualified to “interpret” diagnostic ultrasounds. Note that this code includes “imaging supervision and interpretation.” An interpretation of the ultrasound guidance must be documented in the patient’s medical record in order to separately bill this procedure code



• For ultrasound guidance of nerve block procedures, the recommended CPT code is 76942 - Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation. Report CPT code 76942 in addition to the code for the nerve block itself Medicare Correct Coding Initiative (CCI) edits do not, at present, bundle the nerve block and ultrasound guidance of the nerve block specific to the procedures listed in this guide. It is recommended to check with each private payer regarding their policies on this service. In addition CPT has in recent years changed specific procedure codes to reflect to requirement of image guidance for several types of injections commonly performed by pain specialists. It is recommended to review CPT code descriptions carefully and adhere to the correct coding conventions

• Under the National Correct Coding Initiative, NCCI, which sets CMS payment policy as well as many private payers, one unit of service is allowed for CPT code 76942 in a single patient encounter regardless of the number of needle placements performed. Per NCCI, “The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.


Added section for Allergen Immunotherapy. Added to the section Ultrasonic Guidance for Needle Biopsy - "Separate reimbursement is allowed for 76942 (Ultrasonic Guidance for Needle Biopsy) when submitted with 76645 (Ultrasound, Breast(s) (unilateral or bilateral), B-scan and or real time with image documentation). Removed the bundling guidelines for Hot or Cold Packs. Removed the bundling guidelines for Introduction of Needle or Intracatheter. Section contained information for CPT codes effective January 1, 2006. Removed the bundling guidelines under Casting Application and Strapping - "A4580, ‘cast supplies (e.g., plaster),’ will be considered incidental to casting/strapping codes 29000- 29799. The cost of the cast or splint is included in the basic value of the application and its corresponding code and does not provide separate reimbursement."

 CPT codes 76942, 77002, 77003, 77012, and 77021 describe radiologic guidance for needle placement by different modalities. CMS payment policy allows one unit of service for any of these codes at a single patient encounter regardless of the number of needle placements performed. The unit of service for these codes is the patient encounter, not number of lesions, number of aspirations, number of biopsies, number of injections, or number of localizations.


Limitations

** Dry needle trigger point injections are not considered medically necessary, as there is insufficient evidence of therapeutic value.

** Injections used on a routine basis (e.g., on a regular periodic and continuous basis, for patients with chronic non-malignant pain syndromes) are not considered medically necessary.

** Only injections of local anesthetics and corticosteroids are covered.

** Injections consisting of only saline and/or botanical substances are not supported in the peer-reviewed literature and are not considered medically necessary.

Note: The services represented by CPT codes 76942 and 77022 are considered incidental to injection procedure codes 20550, 20552 and 20553, and will not be separately reimbursed when submitted with these procedure codes. Modifier 59 will not override this bundling edit. Any combination of trigger point injections (20552, 20553) when billed > 3 times in 90-day period will be denied.

Q: To report code 76942 correctly, is it required that the ultrasound guide the actual ultrasound guide the actual “needle puncture needle puncture”?

A: Yes. Code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation, requires that the ultrasound is used to guide the needle such as for that the ultrasound is used to guide the needle such as for a needle biopsy or fine needle aspiration (FNA) of an organ or body area.

It is not required that the ultrasound guidance be used specifically for the insertion of the needle through the skin but the imaging must be used to guide the needle placement in order to report the code.



Q: Would it be appropriate to report code 76942, Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation twice when there is more supervision and interpretation, twice when there is more than one lesion in the breast?

A: From a CPT coding perspective code From a CPT coding perspective, code 76942 should be should be reported per distinct lesion that requires separate needle p ,p lacement. Therefore, if several passes are made into two separate lesions in the same organ (ie, two lesions in same breast), then code 76942 would be reported twice.

2013  CPT Code  CPT Code Descriptor    Global Payment  Professional Payment   Technical Payment    


76942  Ultrasonic guidance for needle placement (e.g., biopsy, aspiration injection, localization device), imaging supervision and interpretation

$61.22

$34.01

$27.21



Example  Column 1 Code/Column 2 Code 47370/76942

CPT Code 47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency

CPT Code 76942 – Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation


CPT code 76942 should not be reported and modifier 59 should not be used if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure. Code 76942 may be reported with modifier 59 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure.

Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ


Arthrocentesis

20604 Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting  (Do not report 20600, 20604 in conjunction with 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)


20611 Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (Do not report 20610, 20611 in conjunction with 27370, 76942) (If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021)



CMS proposed CPT code 76942 (Ultrasonic guidance for needle placement (for example, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) as a potentially misvalued code because of the high frequency with which it is billed with CPT code 20610 Arthrocentesis aspiration and/or injection; major joint or bursa (for example, shoulder, hip, knee joint, subacromial bursa). One CMD suggests that the payment for CPT code 76942 and CPT code 20610 should be combined to reduce the incentive for providers to always provide and bill separately for ultrasound guidance.

CMS notes that they are making a proposal regarding the direct PE inputs for CPT code 76942 as described above. Claims data show that the procedure time assumption for CPT code 76942 is longer than the typical procedure with which the code is billed (for example, CPT code 20610). CMS believes that the discrepancy in procedure times and the resulting potentially inaccurate payment raises a fundamental concern regarding the incentive to furnish ultrasound guidance. CMS believes this concern spans more than just an individual code for ultrasound guidance. Accordingly, they have proposed additional ultrasound guidance codes as potentially misvalued   in Table 12 (below). CMS sought public comment on including these codes as potentially misvalued codes.

CMS decided in the final rule to move forward with evaluating CPT code 76942 as a potentially misvalued code. This action is consistent with a comment received recommending that CMS delay action until the AMA RUC acts because CMS routinely considers AMA RUC recommendations through the usual review of potentially misvalued codes. Thus, CMS would seek the AMA RUC recommendation before re-valuing.


Payment Information

The following chart provides payment information that is based on the national unadjusted Medicare physician fee schedule for the ultrasound services discussed in this guide. Payment will vary by geographic region. Use the "Professional Payment" column to estimate reimbursement  to the physician for services provided in facility settings.

Ambulatory Payment Classification (APC) codes and payments are used by Medicare to reimburse Outpatient Hospitals and ASCs under the Hospital Outpatient Prospective Payment System (OPPS). Payment is based on the national unadjusted OPPS amounts. The actual payment will vary by location.



CPT Code       CPT Code Descriptor   Global Payment      Professional Payment  Technical Payment  APC Code  APC Payment

76942

Ultrasonic guidance for needle placement (e.g., biopsy, aspiration injection, localization device), imaging supervision and interpretation

$61.22

$34.01

$27.21

 Packaged Service

No Payment

Reimbursement changes for CPT code 76942 

In the December 2013 issue of Network Update, you were notified of the following: For claims with dates of service on or after March 17, 2014, Anthem Blue Cross and Blue Shield (Anthem) in Indiana, Kentucky, Missouri, Ohio and Wisconsin (individually referred to herein as the Health Plan), will no longer reimburse CPT® code 76942 (Ultrasonic guidance for needle placement) when it is reported with 27096, 32554, 32555, 32556, 32557, 37760, 37761, 43232, 43237, 43242, 45341, 45342, 64479-64484, 64490-64495, 76975, 0213T-0218T, 0228T-0213T, 0232T, 0249T, and 0301T.

After our December 2013 issue published, the Current Procedural Terminology (CPT) parenthetical guideline was updated to include three additional CPT codes: 10030, 19083 and 19285.

As a result, we are notifying you of the following:

• Effective March 17, 2014, the Health Plan will no longer reimburse CPT code 76942 when it is reported with 10030, 19083, 19285.

• Effective May 19, 2014, the Health Plan will no longer override the edit when Modifier 59 is appended to either 76942 and 10030, 19083 and 19285. If you have questions, please contact your local Network Relations consultant.

Bundling Guidelines

Added the following information to Introduction of Needle or Intracatheter into a Vein: Removed December 31, 2005 deleted CPT codes 90780, 90781, 90782, and 90784. Added new 2006 CPT codes 90760, 90761, 90765, 90766, 90767, 90768, 90772, 90773, 90774, and 90775.

Breast Ultrasound

• For characterization of a breast nodule the recommended CPT code is 76645 (Breast ultrasound).

• For performing code 10022. A cyst drainage may be reported using 19000.

• For percutaneous needle core biopsy using imaging guidance use CPT code 19102.

• Ultrasound guidance of all percutaneous procedures described above should be reported separately. The recommended code is 76942.

• If performing a diagnostic breast ultrasound evaluation and an ultrasound guided needle procedure during the same patient encounter all three codes may be billed: the diagnostic ultrasound (76645), the ultrasound guidance (76942) and the biopsy (19102). Medicare CCI edits do not, at present, bundle the breast ultrasound and the ultrasound guidance of the biopsy, but some private payers may.

Thyroid Ultrasound

• 76536 (Soft tissues of head and neck ultrasound).

• For percutaneous needle core biopsy, use code 60100. Image-guided,

• For ultrasound guidance of a thyroid biopsy or cyst aspiration use CPT code 76942. Report 76942 in addition to the code for the primary procedure (e.g., 60100, 10022).

• Medicare CCI edits do not currently bundle the thyroid ultrasound and the ultrasound guidance of the biopsy, but some private payers may.

Abdominal Ultrasound and FAST Exam

• To bill for the evaluation of a single organ within the abdomen use code 76705 (abdominal ultrasound, limited or follow-up). To bill for Focused Abdominal Sonography for Trauma (FAST) exam, also use code 76705.

• For ultrasound guidance of a needle procedure to any abdominal organ, use 76942. Report 76942 in addition to the code for the primary procedure (e.g., 49080). Vascular Ultrasound

• For evaluation of carotid arteries, use codes 93880, duplex scan of extracranial arteries, complete bilateral study or 93882, unilateral or limited study.

• For evaluation of extremity veins for venous incompetence or deep vein thrombosis, use codes 93970, duplex scan of extremity veins; complete bilateral study or 93971, unilateral or limited study.

• Medicare has created code G0365 to be used for vessel mapping for hemodialysis access. The code includes evaluation of the relevant arterial and venous vessels.

• The limited extremity venous duplex code (93971) is used for all other  vein mapping. Check with your payers for coverage guidelines on this procedure. In some cases it is not paid in the absence of a previous condition such as severe varicose veins or previous deep vein thrombosis.

• CPT codes 36475, +36476, 36478, +36479 are used to describe saphenous vein ablation procedures using the radiofrequency and laser methods. These codes are inclusive of all imaging guidance; ultrasound guidance of these procedures is not separately reportable. Although carrier policies vary, typically preoperative extremity duplex to identify and characterize the venous incompetence can still be reported separately. The recommended codes for that procedure are 93970 and 93971 – Duplex scan of extremity veins, depending upon whether the study is complete and bilateral or limited and unilateral.

• If the technical component services of the vascular studies are performed by sonographers, some Medicare Carriers require that the your local carrier’s non-invasive vascular ultrasound coverage policy to learn their requirements. The credentialing requirement does not apply if the physician performs the technical component of the vascular study.

Intraoperative Ultrasound

• has been established and to evaluate the anastomosis may be billed using CPT code 76998. Use of Modifiers
• indicating that only the professional service was provided, physicians must be attached to the CPT code for the ultrasound service. Payers will not reimburse physicians for the technical component in the hospital setting.
• If reporting a surgical procedure such as a biopsy on the same day E/M service must be “... above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.” (CPT Assistant, May 2003.) Be sure to document in the patient’s record all components of the E&M service.

CPT Code CPT Code Descriptor Global Payment Professional Payment

Technical Payment APC Code APC Payment

76536 Ultrasound of soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation $123.22 $27.23 $95.99 0266 $96.31

76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation $89.47‡ $ 26.50 $62.92‡ 0265 $62.92

76705 Ultrasound, abdominal, real time with image documentation; limited (e.g., single organ, quadrant, follow-up) $109.94 $28.59 $81.35 0266 $96.31

76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation $206.61 $33.02 $173.59 Packaged Service No Payment

76998 Ultrasonic guidance, intraoperative No Payment $65.01 No Payment Packaged Service No Payment

93880 Duplex scan of extracranial arteries; complete bilateral study $181.74‡ $29.61 $152.13‡ 0267 $152.13

93882 unilateral or limited study $172.21‡ $20.08 $152.13‡ 0267 $152.13

93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study $185.83‡ $33.70 $152.13‡ 0267 $152.13

93971 unilateral or limited study $118.43‡ $22.12 $96.31‡ 0266 $96.31

G0365 Vessel mapping of vessels for hemodialysis access (Services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemo