Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intravascular ultrasound (37253), an injection procedure 
for extremity venography (36005), a transluminal balloon angioplasty (37249), venography (75822, 75825), 
and additional moderate sedation services (99153) provided on August 26, 2021. 
 
You asked the Plan to pay for an intravascular ultrasound, an injection procedure for extremity venography, a 
transluminal balloon angioplasty, venography, and additional moderate sedation services. You say that you 
have provided records to support the level of service. The Plan denied your request. The Plan says the provided 
records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that radiology and other 
diagnostic services furnished to hospital outpatients are paid under the OPPS to the hospital. 
 
In this case, the CPT Code Manual definition of code 37253 is "Intravascular ultrasound (noncoronary vessel) 
during diagnostic evaluation and/or therapeutic intervention, including radiological supervision and 
interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure)." 
The definition of code 36005 is "Injection procedure for extremity venography (including introduction of 
needle or intracatheter)." 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for an intravascular ultrasound and an injection procedure for 
extremity venography. Our reviewer says that codes 37253 and 36005 do not meet criteria for reimbursement. 
Our reviewer found that with regard to CPT code 37253 the operative report does not describe a guidewire 
threaded through needle into a noncoronary blood vessel and needle is removed. An intravascular ultrasound 
catheter is placed and images obtained. The operative report describes a "real-time ultrasound." In this case 
CPT code 37253 cannot be verified. With regard to CPT code 36005, the injection procedure would be 
inclusive to the balloon angioplasty performed. The operative report does not document a separate procedure 
for injection. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intravascular ultrasound and an injection procedure for extremity 
venography. 
 
We have confirmed that codes 37249, 75822, and 75825 are column II codes to column I code 37238. These 
codes have not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, 
Medicare billing criteria have not been met for a transluminal balloon angioplasty and venography. 
 
The records suggest that additional moderate sedation services were rendered in an outpatient facility. CPT 
code 99153 has a professional/technical component indicator of 3. This means that the payment for the 
technical component of this code is included in the payment to the facility and is the responsibility of the 
facility to any vendor. Therefore, we decided that the Plan does not have to pay for an intravascular ultrasound 
(37253), an injection procedure for extremity venography (36005), a transluminal balloon angioplasty (37249), 
venography (75822, 75825), and additional moderate sedation services (99153) provided on August 26, 2021.