Billing and Coding: Peripheral Venous Ultrasound

This Billing and Coding Article provides billing and coding guidance for
Proposed Local Coverage Determination (LCD) DL35451 Peripheral Venous
Ultrasound. Please refer to the LCD for reasonable and necessary requirements.  
  
**Coding Guidance**

**Notice:** It is not appropriate to bill Medicare for services that are not
covered (as described by the entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.

**Note:** When an uninterpretable study results in performing another type of
study, only the successful study should be billed.

**Note:** Multiple duplex scans plus noninvasive physiologic studies of the
upper and lower extremities (93970, 93971, 93922 and 93923) and 93924-93931
cannot be billed on the same day.

The use of a simple hand-held or other Doppler device that does not produce
hard copy data or that produces a record that does not permit analysis of
bidirectional vascular flow, is considered to be part of the physical
examination of the vascular system and is not separately reported.  
  
**CPT code 93971**

Consistent with the LCD, doppler ultrasound scanning is the current standard
for the preoperative evaluation of reflux in patients with chronic venous
insufficiency.

Correct coding guidelines indicate that CPT code 93971 should be used to
report either a limited bilateral or a complete unilateral study. It would not
be appropriate to report -50 modifier with CPT code 93971 for a limited
bilateral study.  
  
**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. Images of all relevant areas, both normal and abnormal, should be recorded and stored in a retrievable format (electronic preferred).
  5. A signed final report of the ultrasound findings and impression should be included in the patient's medical record and is the definitive documentation of the study. The final report should include but is not limited to the following demographic components: 
    * A description of examination findings, using appropriate anatomic and ultrasound terminology. (Use of acronyms and abbreviations should be avoided)
    * The concluding statements or summary of the report should include these components: 
      * An impression, conclusion, or summary statement
      * A specific diagnosis or differential diagnosis, if appropriate
      * A recommendation for follow-up studies, if clinically applicable
      * An accounting of any failure to include standard views or other necessary components (as listed in the appropriate practice parameter)
      * If prior relevant imaging studies were reviewed, a statement of comparison should be included
      * Details concerning any provider-to-provider communication in cases in which a delay in communication may have an adverse effect on the patient's outcome.
  6. An order from the treating physician/nonphysician practitioner as required by CFR, Title 42, Volume 2, Chapter IV, Part 410.32(a) Ordering diagnostic tests.
  7. The medical record for patients with known venous thrombosis on therapy should reflect what clinical change occurred and how the change in thrombus burden will alter treatment.