Article - Billing and Coding: Non-Invasive Cerebrovascular Studies (A57592)

CMS National Coverage PolicyItalicized fontrepresents CMS national NCD language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national NCD language/wording.Title XVIII of the Social Security Act section 1833 (e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Title XVIII of the Social Security Act section 1862 (a) (1) (A) allows coverage and payment of those items or services that are considered to bemedically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of the Social Security Act section 1862 (a) (1) (D) excludes Medicare payment for any expenses incurred for items or services that are investigational or experimental.Title XVIII of the Social Security Act section 1862 (a) (7) excludes routine physical examinations and services from Medicare coverage.42 CFR, Section 410.32 (a) Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic tests indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiarys specific medical problem. Tests not ordered by the physician or other qualified non-physician provider who is treating the patient are not reasonable and necessary (see 42 CFR 411.15(k) (1).42 CFR, Section 410.32 (b) Diagnostic x-ray and other diagnostic tests. (1) Basic rule. .. all diagnostic x-ray and other diagnostic tests covered under section 1861(s)(3) of the Act and payable under the physician fee schedule must be furnished under the appropriate level of supervision by a physician as defined in section 1861 of the Act. Services furnished without the required level of supervision are not reasonable and necessary. (see 42 CFR 411.15(k)(1)).CMS Pub 100-02Medicare Benefit Policy Manual, Chapter 15  Covered Medical and Other Health Services, Section 80  Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.CMS Pub 100-03Medicare National Coverage Determinations Manual, Chapter 1  Coverage Determinations Part 1, Section 20.17 - Noninvasive Tests of Carotid Function.Part 4, Sections220.5 - Ultrasound Diagnostic Procedures and300.1 - Obsolete or Unreliable Diagnostic Tests.CMS Pub 100-04Medicare Claims Processing Manual, Chapter 13  Radiology Services and Other Diagnostic Procedures, Sections 10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures and20  Payment Conditions for Radiology Services.Chapter 16  Laboratory Services, Section 40.2  Payment Limit for Purchased Services.CMS Pub 100-08,Medicare Program Integrity Manual, Chapter 13  Local Coverage Determinations, Section 13.5.1  Reasonable and Necessary Provisions in LCDs.CMS Publication 100-09,Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD.Documentation RequirementsAdequate 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 practitioners 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 GuidelinesEach patients 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 patients 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 patients 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 patients medical record.Preventive and/or screening services unless covered in Statute are not covered by Medicare.