Billing and Coding: Non-Invasive Cerebrovascular Studies

The billing and coding information in this article is dependent on the
coverage indications, limitations and/or medical necessity described in the
related LCD.

**Documentation Requirements**  
Adequate documentation is essential for high-quality patient care and to
demonstrate the reasonableness and medical necessity of the study(ies).
Documentation must support the criteria for coverage as described in the
Coverage Indications, Limitations, and/or Medical Necessity section of this
LCD. There should be a permanent record of the studies performed and the
interpretation. The documentation should include a description of the studies
performed and any contrast media and/or radiopharmaceuticals used. Any known
significant patient reaction or complications should be recorded. Comparison
with prior relevant studies needs to be addressed in the documentation along
with both normal and abnormal findings. Variations from normal should be
documented along with the measurements. The report should address or answer
any specific clinical questions. If there are factors that prevent answering
the clinical questions, this should be explained in the documentation.
Retention of the ultrasound examination images should be consistent both with
clinical need and with relevant legal and local health care facility
requirements.  
  
If the provider of the study is other than the ordering/referring
physician/nonphysician practitioner, that provider must maintain a copy of the
test results and interpretation, along with copies of the ordering/referring
physician/nonphysician practitioner's order for the studies. This order is
required to provide adequate diagnostic information to the performing
provider. The physician/nonphysician practitioner must state the clinical
indication/medical necessity for the study in his/her order for the test. The
provider is responsible for ensuring the medical necessity of procedures and
maintaining the medical record, which must be available to Medicare upon
request. Results of all testing must be shared with the referring physician.
Non-invasive vascular studies are medically reasonable and medically necessary
only if the outcomes will be utilized in the clinical management of the
patient.  
  
Documentation must be provided supporting the need for more than one imaging
study or a repeat preoperative scan.  
  
 **Utilization Guidelines**  
Each patient's condition and response to treatment must medically warrant the
number of services reported for payment. Medicare requires the medical
necessity for each study reported to be clearly documented in the patient's
medical record.  
  
Frequency of follow-up studies will be carefully monitored for medical
necessity, and it is the responsibility of the physician/provider to maintain
documentation of medical necessity in the patient's medical record.  
  
Only one Doppler preoperative scan is considered reasonable and necessary for
bypass surgery. If a more current preoperative scan is indicated for a patient
with multiple comorbidities having difficulty being stabilized for surgery or
a change in condition, the medical record would need to support the medical
necessity of the second scan.  
  
Re-evaluation of existing carotid stenosis. Patients demonstrating a diameter
reduction of greater than 50% with symptoms and those patients with > 60% with
no symptoms are normally followed on an annual basis. If patients become
symptomatic of carotid disease repeat duplex scans are allowed without regard
to the above schedule.  
  
Follow-up after a carotid endarterectomy (outside the global period). These
patients are normally followed with duplex ultrasonography on the affected
side at 6 weeks, 6 months, and annually thereafter unless symptoms develop.
During the first year, follow-up studies should be on the ipsilateral side
unless signs and symptoms or previously identified disease in the
contralateral carotid artery provide indications for a bilateral procedure.  
  
Multiple cerebrovascular procedures may be allowed during the same encounter
given the physician/non-physician can demonstrate medical necessity as
documented in the patient's medical record.  
  
Preventive and/or screening services unless covered in Statute are not covered
by Medicare.