CPT 93922, 93923, 93924, 93925- BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES

CPT CODE and Description

93922 LIMITED BILATERAL NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, (EG, FOR LOWER EXTREMITY: ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS BIDIRECTIONAL, DOPPLER WAVEFORM RECORDING AND ANALYSIS AT 1-2 LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES PLUS VOLUME PLETHYSMOGRAPHY AT 1-2 LEVELS, OR ANKLE/BRACHIAL INDICES AT DISTAL POSTERIOR TIBIAL AND ANTERIOR TIBIAL/DORSALIS PEDIS ARTERIES WITH, TRANSCUTANEOUS OXYGEN TENSION MEASUREMENT AT 1-2 LEVELS) – average fee payment – $90 – $100

93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia) (USV Upper Arterial W/ABI Non)

93924 NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ARTERIES, AT REST AND FOLLOWING TREADMILL STRESS TESTING, (IE, BIDIRECTIONAL DOPPLER WAVEFORM OR VOLUME PLETHYSMOGRAPHY RECORDING AND ANALYSIS AT REST WITH ANKLE/BRACHIAL INDICES IMMEDIATELY AFTER AND AT TIMED INTERVALS FOLLOWING PERFORMANCE OF A STANDARDIZED PROTOCOL ON A MOTORIZED TREADMILL PLUS RECORDING OF TIME OF ONSET OF CLAUDICATION OR OTHER SYMPTOMS, MAXIMAL WALKING TIME, AND TIME TO RECOVERY) COMPLETE BILATERAL
STUDY

93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY

ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program:

Group 1 Paragraph: Peripheral Arterial Examinations (93923-93931)

When CPT code 93926 is used to perform a limited study for a follow-up of bypass surgery, use the diagnosis code Z48.89 (encounter for other specified surgical aftercare). For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

HEMODIALYSIS ACCESS EXAMINATION (93990)

CPT code 93990 is the only code to be used for reporting a duplex scan of hemodialysis access since, by definition; it includes arterial inflow, body of access, and venous outflow. Therefore, it would be incorrect to report duplex scans for arteries or veins in addition to CPT code 93990.

Billing for monitoring of hemodialysis access using CPT codes for non-invasive vascular studies other than 93900 is considered a misrepresentation of the service actually provided and should be denied. If this is found, appropriate corrective actions will be undertaken.

If abnormal function is strongly suspected but not found, use V71.89 and list abnormal signs or symptoms.

A. Ordering of tests:

NIVT procedures will not be covered when performed based on internal protocols of the testing facility. The physician treating the patient must specifically order the procedures, in writing. The ordering physician must provide the performing provider of the diagnostic test the indication for the study so that the provider of service can make sure the study is medically necessary and within guidelines. The order to the independent diagnostic testing facility (IDTF) must be in writing. Orders to
other providers may be oral, but must be reduced to writing.

42 CFR§410.32 indicates that diagnostic tests, to be covered, must be ordered by the practitioner that treats the patient. The treating physician is the practitioner responsible for the treatment of the patient and who orders the test to use the results in the management of the beneficiary’s specific medical problem(s). Consulting physicians may also order tests.

B. Supervision:

General Supervision is defined as: “The procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.” (PM B-01-28, April 29, 2001) CMS has determined the following list of procedures require general physician supervision effective July 1 2001:

93875 & TC, 93880 & TC, 93882 & TC, 93886 & TC, 93888 & TC, 93922 & TC, 93923 & TC, 93924 & TC, 93925 & TC, 93926 & TC, 93930 & TC, 93965 & TC, 93970 & TC, 93971 & TC (PM B-01-28, April 19, 2001)

Coding Guidelines

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

The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) 5-year review identification workgroup captured CPT code 93922 for excessive growth despite an increasing awareness of peripheral vascular disease by medical providers. After further review, the entire family of noninvasive physiologic arterial testing codes including CPT codes 93922, 93923, and 93924 were then subject to re-evaluation. The concern for this growth lies in the Category I CPT descriptor. The introductory wording within the “Noninvasive Vascular Diagnostic Studies” section specifically states that the use of a simple hand-held Doppler device to determine an ankle/ brachial index (or ABI) is part of the physical exam and included in standard Evaluation and Management (E&M) billing. Unfortunately, there were still vagaries in the 2010 CPT descriptions: code 93922 includes “. . . (eg, ankle/ brachial indices, . . .” and code 93923 states “. . . (eg, segmental blood pressure measurements . . .,” which may lead providers to assume otherwise. To prevent the incorrect billing of CPT code 93922 when an ABI is performed in an office setting, the base CPT code descriptions and the introductory wording for this section of the CPT manual have been altered for 2011 to define the minimum requirements for reporting these services following the Intersocietal Commission for the Accreditation of Vascular Laboratories (or ICAVL) standards.

First, the differences between CPT codes 93922 and 93923 were addressed. “Single” and “multiple” were changed to “one or two levels” and “three or more levels,” respectively. These levels were defined in the lower extremity as high thigh, low thigh, calf, ankle, metatarsal, and toes. In the upper extremity, options include arm, forearm, wrist, and digits. Additionally, there are situations where three or more levels are evaluated in a single extremity due to amputation or extensive wound issues in the contralateral limb. In this setting, the 2010 reporting standards required CPT code 93923 with the -52 (reduced services) modifier. In 2011, such a situation (three or more levels, unilateral) is now appropriately described by the lesser valued CPT code, 93922. A study which involves one or two levels in a single extremity (unilateral) still requires CPT code 93922 have the -52 modifier appended. If the evaluation requires the testing be repeated after compression of a fistula for steal syndrome, compression of the radial artery for assessing completeness in the palmar arch, cold immersion of the digits for vasospasm, or assuming the “surrender” position for thoracic outlet syndrome, only a single level (bilaterally) is required since an exception in CPT code 93923 allows for “single level measurements with provocative functional maneuvers.” These four situations are all examples of valid “provocative functional maneuvers.”

The introductory wording to the “Noninvasive Vascular Diagnostic Studies” section was altered to clarify the specific vascular laboratory testing options. All three noninvasive physiologic arterial studies necessitate an ABI plus at least one other physiologic evaluation. In the lower extremity, the ABI must now be calculated at both the dorsalis pedis and the posterior tibial arteries. Previously, only one pedal artery assessment was required but the newer guidelines follow the ICAVL recommendations for a complete study. In the upper extremity, systolic occlusion pressures must be determined at only one vessel (brachial, radial, or ulnar). In addition to these calculations for either the upper or lower extremity, at least one of the following three physiologic testing has to occur: bidirectional Doppler waveform recording and analysis, volume plethysmography, or transcutaneous oxygen tension measurements. Assessments other than these three options are no longer appropriate to submit to the insurance carrier with CPT codes 93922 and 93923.

CPT code 93924 has had additional wording inserted in 2011, which mandates use of either bidirectional Doppler waveform recording and analysis, or volume plethysmography on both lower extremities. These assessments are required at rest and then at periodic timed intervals using a standardized protocol. The time of onset of claudication, the maximal walking time, and the time to recovery must be recorded. Additionally, because the CPT code descriptor states “treadmill,” no other form of exercise is permitted, such as toe raises or ambulation in the office corridor.

When both the upper and lower extremities are assessed in the same setting, the noninvasive physiologic study may be reported twice. This necessitates appending the modifier 59 to the second procedure.

Overview

Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative, and postoperative evaluation of peripheral artery disease in the vascular surgery practice or internal medicine. Also it is a useful tool for the preoperative podiatric evaluation of the diabetic patient or other signs or symptoms indicative of peripheral vascular disease, or one who has intermittent claudication which have a bearing on the patient’s candidacy for foot surgery.

A form of plethysmography is the venous occlusive pneumoplethysmography. In the setting of the hospital vascular laboratory, this technique is considered a reasonable and necessary procedure for the diagnostic evaluation of suspected peripheral arterial disease. It is unsuitable for routine use in the physician’s office.

A number of other plethysmographic methods have been developed which make use of phenomena such as changes in electric impedance or changes in segmental blood pressure at constant volume to assess regional perfusion. Several of these methods have reached a level of development, which makes them clinically valuable.

Guidelines

Medicare coverage is extended to those procedures listed in Category I below when used for the accepted medical indications mentioned above. The procedures in Category II are still considered experimental and are not covered.

Category I – Covered

• Segmental Plethysmography – Included under this procedure are services performed with a regional plethysmograph, pulse volume recorder, recording oscillometer, and a differential plethysmograph.
• Ultrasonic Measurement of Blood Flow (Doppler) – While not strictly a plethysmographic method, it is also a useful tool in the evaluation of suspected peripheral vascular disease or preoperative screening of podiatric patients with suspected peripheral vascular compromise.
• Electrical Impedance Plethysmography.
• Oculoplethysmography – See NCD 20.17 Noninvasive Tests of Carotid Function.
• Strain Gauge Plethysmography – This test is based on recording the non-pulsatile aspects of inflowing blood at various points on an extremity by a mercury-in-silastic strain gauge sensor. The instrument consists of a chart recorder, a recording manometer and an automatic cuff inflation and deflation system.

Category II – Experimental
The following methods have not yet reached a level of development to allow their routine use in the evaluation of suspected peripheral vascular disease.

• Mechanical Oscillometry – This is a non-standardized method, which offers poor sensitivity and is not considered superior to the simple measurement of peripheral blood pressure.
• Photoelectric Plethysmography – This method is considered useful only in determining whether a pulse is present and does not provide reproducible measurements of blood flow.
• Inductance Plethysmography – This method is considered experimental and does not provide reproducible results.
• Capacitance Plethysmography – This method is considered experimental and does not provide reproducible results.

Differential plethysmography, is a system, which uses an impedance technique to compare pulse pressures at various points along a limb, with a reference pressure at the wrist level or mid-brachial. Usually performed in the physician’s office, it is not clear whether this technique, meets the definition of plethysmography because quantitative measurements of blood flow are usually not made. The differential plethysmography system is a blood pulse recorder of undetermined value, which has the
potential for significant overutilization. Reimbursement for studies done by techniques other than venous occlusive pneumoplethysmography should be denied, at least until additional data on these devices, including controlled clinical studies, become available.

Arterial/Venous Studies

1. Peripheral arterial studies (Extremity/Visceral) (93922-93931) Indications for:
   Upper and lower extremity physiologic studies (CPT-4 codes 93922 and 93923),
   Lower extremity studies (CPT-4 codes 93925 and 93926), and
   Upper extremity duplex studies (CPT-4 codes 93930 and 93931)

Utilization Guidelines

A. Training and Certification

1. 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 and maintain any applicable documentation. A vascular diagnostic study may be personally performed by a physician or a technologist.

The GAO Report to Congressional Committees entitled Medicare Ultrasound Procedures. Consideration of Payment Reforms and Technician Qualifications Requirements states that “Findings from several peer-reviewed studies, the Medicare Payment Advisory Commission, and ultrasound-related professional organizations support requiring that sonographers either have credentials or operate in facilities that are accredited, where specific quality standards apply. In some localities and practice settings, CMS or its contractors have required that sonographers either be credentialed or work in an accredited facility.” (GAO-07-734)

2. All non-invasive vascular diagnostic studies must be performed under at least one of the following settings:
   a. performed by a physician who is competent in diagnostic vascular studies or under the general supervision of physicians who have demonstrated minimum
   entry level competency by being credentialed in vascular technology, or
   b. performed by a technician who is certified in vascular technology, or
   c. performed in facilities with laboratories accredited in vascular technology.
3. One or more technologists in each vascular laboratory must be certified by a credentialing board recognized by the Intersocietal Commission for Accreditation of Vascular Laboratories (ICAVL) or the National Council for Certifying Agencies (NCCA) or the International Standards Organization (ISO) 17024).
4. Laboratories may be certified by the Intersocietal Commission for the Accreditation of Vascular Laboratories. Certification of the laboratory itself supersedes the requirement for certification of individual technologists.
   If a certified technologist supervises technologists who are not certified, the certified RVT must: provide direct supervision; and sign the record of the test and attest to the quality of the examination
5. Transcutaneous Oxygen measurement (93922-93923) may be performed by personnel possessing the following credentials obtained from the National Board of Doving and Hyperbaric Medicine Technology (NBDHMT):
   a. Certified Hyperbaric Technologist (CHT)
   b. Certified Hyperbaric Registered Nurse (CHRN)

Peripheral arterial studies (Extremity / Visceral) (93922-93931)

1. Procedures that are reimbursed include Duplex scan (93925, 93926, 93930, 93931)
   a. Duplex scanning and physiological studies are reimbursed during the same encounter if the physiological studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease.
   b. Studies of the lower and upper extremities on the same day may be clinically indicated when the graft extends from the upper to lower extremity, i.e. axillo-femoral grafts. The patient’s record should document that signs and/or symptoms are present in both areas.
2. CPT-4 codes 93922 and 93923 are considered to be a part of code 93924.
   CPT-4 code 93923 describes the studies considered most useful in determining the presence or absence of extremity arterial insufficiency. Duplex studies are sometimes needed in addition to 93923. The patient’s medical record should document the need for both studies; e.g., to evaluate vascular trauma, evaluate abnormalities found on physiological studies, thromboembolic events or aneurysmal disease, patients in whom contrast studies are contraindicated, or follow-up of bypass grafts. Studies of upper and lower extremities on the same day are sometimes clinically indicated. Examples would be: To help determine surgical or percutaneous management, it may help to determine the extent of the lesion To assess the radial artery as a resource for coronary bypass The patient’s medical record should indicate appropriate signs or symptoms are present in both areas; the diagnoses listed should reflect anatomic-specific conditions where possible.

Appeals of Medical Necessity Denials

• Failure to appeal inappropriate denials
• e.g., FCSO denials of 93970 and 93923 when performed on the same date of service
• Not a CCI edit – a carrier edit? Violating their own LCD?
• Assuming medical necessity is demonstrated (ICD-9 in LCD), these claims should be paid but must be appealed
• 93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension
  measurements at 3 or more levels), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with reactive hyperemia)
• (When only 1 arm or leg is available for study, report 93922 for a unilateral study when recording 3 or more levels or when performing provocative functional maneuvers)*
• (Report 93923 only once in the upper extremity(s) and/or once in the lower extremity(s). When both the upper and lower extremities are evaluated in the same setting, 93923 may be reported twice by adding modifier 59 to the second procedure)
• (For transcutaneous oxyhemoglobin measurement in a lower extremity wound by near infrared spectroscopy, use 0286T)
• (Do not report 93923 in conjunction with 0337T)
• * /fww comment: Is this a false claim and/or conspiracy to commit fraud?
• 93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study
• (Do not report 93924 in conjunction with 93922, 93923)

EXTREMITY ARTERIAL STUDIES (INCLUDING DIGITS)

93923 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental blood pressure measurements with bidirectional Doppler waveform recording and analysis, at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental volume plethysmography at 3 or more levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus segmental transcutaneous oxygen tension measurements at 3 or more level(s), or single level study with provocative functional maneuvers (eg, measurements with postural provocative tests, or measurements with
reactive hyperemia).

93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and Physician – Procedure Codes, Section 2- Medicine, Drugs and Drug Administration Version 2020 Page 89 of 103 analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study (Do not report 93924 in conjunction with 93922, 93923)

DESCRIPTION

Cardiovascular disease (CVD) describes the category of diseases caused by atherosclerosis, the accumulation of plaque in the walls of arteries. Atherosclerosis may be present for many years without noticeable symptoms. Plaques impede blood flow as they grow in size and when this occurs in the coronary arteries, it is referred to as
coronary artery disease (CAD). CAD is the most common cause of death in developed countries.

CVD risk testing is utilized to indicate the chances of having a coronary event. The most common tests to determine cardiac risk are high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol and triglycerides (often referred to as a basic or standard lipid panel).

Risk factors other than LDL cholesterol include a variety of tests such as serum inflammatory markers, comprehensive lipoprotein testing, angiotensin gene testing, prothrombotic factors and other types of gene testing. Given the lack of evidence for clinical utility of any individual risk factor beyond simple lipid measures, it is unlikely that the use of CV risk panels improves outcome. Several clinical trials are underway to evaluate methods aimed at cardiovascular risk reduction, however evidence in the form of randomized controlled trials supporting that treating to target levels of emerging risk factors lowers risk is lacking. Furthermore, no study has provided high-quality evidence that measurement of markers leads to changes in management that improve health outcomes.

COVERAGE CRITERIA
HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage
The following CVD risk tests, individually or as part of a CVD risk panel are considered not medically necessary and therefore non-covered because their clinical value has not been established (this list may not be all-inclusive):

• Apolipoprotein A-1 (apo A-1)
• Apolipoprotein E (apo E)
• ASCVD risk testing (individual or panel) (eg, c-peptide, glycated protein, islet cell antibodies, nonesterified fatty acids (free fatty acids), proinsulin and total insulin)
• Brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP) to predict CVD risk
• Carotid intima media thickness testing
• Coenzyme Q10 (CoQ10)
• Comprehensive lipid panel (eg, Cardio IQ Advanced Lipid Panel, NMR LipoProfile)
• Cortisol
• Cystatin-C
• Fibrinogen
• Galectin-3
• HDL subclass
• Homocysteine
• Iron studies (eg, ferritin, serum iron)
• LDL subclasses (eg, NMR)
• Lipoprotein(a) (Lp[a])
• Lipoprotein-associated phospholipase A2 (Lp-PLA2 or PLAC)
• Lipoprotein remnants (intermediate density lipoproteins [IDL] and small density lipoproteins [sdLDL])
• Long-chain omega-3 fatty acids
• MPO
• Non-invasive measurements of arterial elasticity by means of blood pressure waveforms (e.g., CardioVision MS-2000, CVProfilor, Digital Pulse Analyzer (DPA), Max Pulse and HDI PulseWave)
• Non-invasive calculation and analysis of central arterial pressure waveforms (SphygmoCor)
• Secretory type II phospholipase A2 (sPLA2-11A)
• Serum sterols (eg, Boston Heart Cholesterol Balance Test)
• Singulex SMC testing for risk of cardiac dysfunction and vascular inflammation (eg, SMC Endothelin, SMC
  IL-6, SMC IL 17A, SMC c TnI and SMC TNF-a)
• Skin cholesterol (eg, PREVU)
• Thromboxane metabolite(s) testing
• Troponin I (eg, PATHFAST cTnI-II)
• Vitamin D