Article - Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (A57594)

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 Diagnosis x-ray tests, diagnostic laboratory tests, and other diagnostic 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 11  End Stage Renal Disease, Section 40  Other Services.Chapter 15  Covered Medical and Other Health Services, Section80  Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.CMS Pub 100-03Medicare National Coverage Determinations (NCD) Manual, Chapter 1  Coverage Determinations Part 1, Section20.14  Plethysmography andPart 4, Sections 220.5 - Ultrasound Diagnostic Procedures,CMS Pub 100-04Medicare Claims Processing Manual, Chapter 7  SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section50  Billing Part B Radiology Services and Other Diagnostic Procedures;Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/ Supplier Claims, Sections 140  Monthly Capitation Payment Methods for Physicians Services Furnished to Patients on Maintenance Dialysis. A.  Services Included in Monthly Capitation Payment and180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services;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; andChapter 16  Laboratory Services, Section40.2  Payment Limit for Purchased Services, andChapter 23  Fee Schedule Administration and Coding Requirements, Addendum  MPFSDB Record Layouts.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 as described in the Coverage Indications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent record of the performed studies and 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 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.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.Generally, it is expected that noninvasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services.Only one preoperative scan is considered reasonable and necessary for hemodialysis access site 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.Only one limited study is considered reasonable and necessary post operatively within 72 hours of a saphenous vein ablation, whether surgery is performed on one side or bilaterally.Pre-surgical conduit mapping of the radial artery(ies) should only be accompanied by vein-mapping studies when the arterial studies demonstrate a non-acceptable conduit, or an insufficient conduit is available for multiple bypass procedures.Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support the medical necessity.Documentation must be provided supporting the need for more than one imaging study Doppler flow or vessel mapping and arteriogram.Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins during the same encounter is not appropriate as a general practice or standing protocol, and therefore, generally would not be expected to be done together. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter.Preventive and/or screening services unless covered in Statute are not covered by Medicare.