Local Coverage Determination (LCD): Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (L35751)

Transcription

1 Local Coverage Determination (LCD): Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (L35751) Contractor Information Contractor Name Wisconsin Physicians Service Insurance Corporation LCD Information Document Information LCD ID L35751 Original ICD-9 LCD ID N/A LCD Title Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date N/A Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 07/01/2015 Notice Period End Date 08/15/2015

2 Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS). Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: 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 be medically 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 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 beneficiary s specific medical problem. Tests not ordered by the physician or other qualified non-physician provider who is treating the patient are not

3 reasonable and necessary (see 42 CFR (k) (1). 42 CFR, Section (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 (k)(1)). CMS Pub Medicare Benefit Policy Manual, Chapter 11 End Stage Renal Disease, Section 40 Other Services. Chapter 15 Covered Medical and Other Health Services, Section 80 Requirements for Diagnostic X-rays, Diagnostic Laboratory, and Other Diagnostic Tests. CMS Pub Medicare National Coverage Determinations (NCD) Manual, Chapter 1 Coverage Determinations Part 1, Section Plethysmography and Part 4, Sections Ultrasound Diagnostic Procedures, Thermography, and Obsolete or Unreliable Diagnostic Tests. CMS Pub Medicare Claims Processing Manual, Chapter 7 SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), Section 50 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 and 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 and 20 Payment Conditions for Radiology Services; and Chapter 16 Laboratory Services, Section 40.2 Payment Limit for Purchased Services. CMS Pub , Medicare Program Integrity Manual, Chapter 13 Local Coverage Determinations, Section Reasonable and Necessary Provisions in LCDs. CMS Publication , Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5 - Correct Coding Initiative. Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Overview Non-invasive peripheral venous vascular studies utilize ultrasonic Doppler and physiologic studies to assess the irregularities in blood flow in the venous system. Noninvasive peripheral venous vascular studies include the patient care required to perform the studies, supervision of

4 the studies, and interpretation of study results, with copies for patient records of test results and analysis of all data, including bi-directional vascular flow or imaging when provided. Diagnostic tests must be ordered by the physician who is treating the beneficiary and use the result in the management of the beneficiary s specific medical problem. Services are deemed medically necessary when all of the following conditions are met: 1. Signs/symptoms of ischemia or altered blood flow are present; 2. The information is necessary for appropriate medical and/or surgical management; 3. The test is not redundant of other diagnostic procedures that must be performed. Definitions: Duplex Scans: Duplex combines Doppler and conventional ultrasound, allowing the structure of blood vessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to be seen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds into colors overlaid on the image, representing information about the speed and direction of blood flow. Using spectral Doppler analysis, the duplex scan images provide anatomic and hemodynamic information, identifying the plaque, occlusions and incompetent veins. Duplex scans are in real-time. Physiologic Studies: Functional measurement procedures which include Doppler ultrasound studies, blood pressure and physiologic waveforms, segmental pressure measurements, blood pressure measurements, transcutaneous oxygen tension measurements, exercise testing, and/or plethysmography. These studies do not involve imaging. Doppler Ultrasound: Uses reflected sound waves called physiologic waveforms to evaluate the blood as it flows through a vein. The waveforms bounce off blood cells in a motion that causes a change in the pitch of the sound, called the Doppler effect. These can be measured at a single level, or a segmental (various) limb levels. An audible sound is created and recorded by either an analog recorder or spectral analyzer. Spectral analysis separates the signal into individual components and assigns a relative importance. If there is no blood flow, the pitch does not change. The receiver detects the shift. Exercise testing can be used to analyze the functional significance of vascular disease by reassessing the blood pressure with the Doppler stethoscope after completion of an appropriate amount of stress testing. Plethysmography is a measurement of the volume of an organ or limb section, or flow rate, in response to the inflation and deflation of a BP cuff. Volume measurement procedures include air, impedance or strain gauge methods. I. Peripheral Venous Vascular Studies (93965, 93970, 93971) Indications for peripheral venous vascular examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies, which are medically necessary to determine subsequent treatment, are

5 covered if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedures. A. Deep Vein Thrombosis (DVT) Indications: The signs and symptoms of DVT are relatively non-specific; and due to the risk associated with pulmonary embolism (PE), objective testing is allowed in patients who are candidates for anticoagulation or invasive therapeutic procedures for the following conditions: 1. Clinical signs and/or symptoms of DVT including edema, tenderness, inflammation, and/or erythema. 2. Clinical signs and/or symptoms of pulmonary embolism (PE) including hemoptysis, chest pain, and/or dyspnea. 3. Unexplained lower extremity edema status, post major surgical procedures, trauma, other or progressive illness/condition; surveillance following high-risk surgical procedures, such as orthopedic or pelvic. Individual consideration will be given to surveillance of patients on prolonged bed rest (e.g., due to neurologic, condition / procedures, congestive heart failure, and paradoxical emboli). In general, surveillance is not necessary when effective antithrombotic measures (e.g., anticoagulants, alternating pressure devices) are being used. However, it may be necessary in some patients prior to applying alternating pressure devices or compression dressings under appropriate clinical circumstances. 4. Unexplained lower extremity pain, excluding pain of skeletal origin. 5. Bilateral limb edema is rarely an indicator for medically necessary in the presence of signs and symptoms of heart failure, exogenous obesity, and/or arthritis. B. Chronic Venous Insufficiency Indications: Chronic venous insufficiency may be divided into three categories: primary varicose veins, post-thrombotic (post-phlebitic) syndrome, and recurrent deep vein thrombosis. Peripheral Vascular studies may be indicated in patients with: 1. Ulceration suspected to be secondary to venous insufficiency. These tests may be indicated to confirm this diagnosis by documenting venous valvular incompetence prior to invasive therapeutic treatment. 2. Varicose veins by themselves do not indicate medical necessity, but medical necessity may be indicated when they are accompanied by significant pain or stasis dermatitis. It is not medically necessary to study asymptomatic primary varicose veins. (See WPS policy L30143, Treatment of Varicose Veins of the Lower Extremities). 3. Superficial thrombophlebitis involving the proximal thigh, to investigate whether there was thrombus at the saphenofemoral junction that would demand either anticoagulation or surgical ligation.

6 4. Evaluation is medically necessary in patients with symptoms of recurrent DVT or in patients prior to compression therapy to exclude superimposed acute DVT which may be at risk for embolization with such therapy. C. Venous Mapping Indications: Vein mapping is considered medically reasonable and necessary when the patient s clinical evaluation indicates one of the following: 1. Previous partial harvest of the vein. 2. Previous thrombophlebitis or DVT in the leg. 3. Severe varicose veins. 4. Previous history of vein stripping, ligation, or sclerotherapy. 5. Obesity to the degree it interferes with clinical determination. 6. Other indications must be clearly supported by medical documentation. 7. Vein mapping may be performed prior to creating a dialysis fistula. See section III in this policy on vessel mapping of vessels for hemodialysis. 8. Mapping the saphenous veins prior to scheduled revascularization procedures is covered when it is expected that an autologous vein will be used, but only if there is uncertainty regarding the availability of a suitable vein for bypass. Limitations: 1. Vein mapping as a routine preoperative study is not covered. 2. Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study is indicated for the preoperative examination of potential harvest vein grafts to be utilized during bypass surgery. This is a covered service only when the results of the study are necessary to locate suitable graft vessels. The need for the bypass surgery must be determined prior to the performance of the test. II. Hemodialysis Access Studies (93990) Medicare considers a Doppler flow study medically necessary when the patient s dialysis access site manifests signs or symptoms associated with vascular compromise, and when the results of this test are necessary to determine the clinical course of treatment. Indications: Signs and symptoms in patients impending failure of the hemodialysis access site include: 1. Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.,

7 2. Elevated recirculation of 12 percent or greater, and 3. An otherwise unexplained urea reduction ratio <60 percent, and 4. An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction). III. Vessel Mapping of Vessels for Hemodialysis Access (93970, 93971, 93990, G0365) Indications: Vessel mapping of vessels for hemodialysis access is considered for Medicare payment when it is performed preoperatively prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow in patients with end stage renal disease (ESRD). This is a covered service only when the results of the study are necessary to determine appropriate vessel utilization. The need for a hemodialysis access site must be determined prior to the performance of the test. Limitations: Unless the documentation is provided supporting the necessity of more than one study, Medicare will limit payment to either a Doppler flow study or an arteriogram (fistulogram, venogram), but not both. An example of when both studies may be clinically necessary is when a Doppler flow study demonstrates: Reduced flow (blood flow rate less than 800cc/min or A decreased flow of 25 percent or greater from previous study) and The physician requires an arteriogram to define the problem. Credentialing and Accreditation Standards The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience. A vascular diagnostic study may be personally performed by a physician, a certified technologist, or in a certified vascular testing lab. Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. All non-invasive vascular diagnostic studies must be performed meeting at least one of the following: a. performed by a licensed qualified physician, or b. performed by a technician who is certified in vascular technology, or c. performed in facilities with laboratories accredited in vascular technology.

8 A licensed qualified physician for these services is defined as: d. Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or e. Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and f. Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed. Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body. Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing International s Registered Vascular Specialist (RVS). Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) Vascular Ultrasound Program, or Joint Commission must follow the accrediting body s standards. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

9 999x Not Applicable Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. N/A CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY) DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) VESSEL MAPPING OF VESSELS FOR HEMODIALYSIS ACCESS (SERVICES FOR PREOPERATIVE VESSEL MAPPING PRIOR TO CREATION OF HEMODIALYSIS G0365 ACCESS USING AN AUTOGENOUS HEMODIALYSIS CONDUIT, INCLUDING ARTERIAL INFLOW AND VENOUS OUTFLOW) ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Peripheral Venous Examinations (93965, 93970, and 93971) Group 1Codes ICD-10 Description Code

10 D68.51 Activated protein C resistance D68.52 Prothrombin gene mutation D68.59 Other primary thrombophilia D68.61 Antiphospholipid syndrome D68.62 Lupus anticoagulant syndrome D68.69 Other thrombophilia D75.81 Myelofibrosis D75.82 Heparin induced thrombocytopenia (HIT) D75.89 Other specified diseases of blood and blood-forming organs I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I27.82 Chronic pulmonary embolism I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I Phlebitis and thrombophlebitis of right iliac vein I Phlebitis and thrombophlebitis of left iliac vein I Phlebitis and thrombophlebitis of iliac vein, bilateral I Phlebitis and thrombophlebitis of right popliteal vein I Phlebitis and thrombophlebitis of left popliteal vein I Phlebitis and thrombophlebitis of popliteal vein, bilateral I Phlebitis and thrombophlebitis of right tibial vein I Phlebitis and thrombophlebitis of left tibial vein I Phlebitis and thrombophlebitis of tibial vein, bilateral I Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.8 Phlebitis and thrombophlebitis of other sites I82.1 Thrombophlebitis migrans I Acute embolism and thrombosis of superior vena cava I Chronic embolism and thrombosis of superior vena cava I Acute embolism and thrombosis of other thoracic veins I Chronic embolism and thrombosis of other thoracic veins I Acute embolism and thrombosis of right femoral vein I Acute embolism and thrombosis of left femoral vein

11 I Acute embolism and thrombosis of femoral vein, bilateral I Acute embolism and thrombosis of right iliac vein I Acute embolism and thrombosis of left iliac vein I Acute embolism and thrombosis of iliac vein, bilateral I Acute embolism and thrombosis of right popliteal vein I Acute embolism and thrombosis of left popliteal vein I Acute embolism and thrombosis of popliteal vein, bilateral I Acute embolism and thrombosis of right tibial vein I Acute embolism and thrombosis of left tibial vein I Acute embolism and thrombosis of tibial vein, bilateral I Acute embolism and thrombosis of other specified deep vein of right lower extremity I Acute embolism and thrombosis of other specified deep vein of left lower extremity I Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I Chronic embolism and thrombosis of right femoral vein I Chronic embolism and thrombosis of left femoral vein I Chronic embolism and thrombosis of femoral vein, bilateral I Chronic embolism and thrombosis of right iliac vein I Chronic embolism and thrombosis of left iliac vein I Chronic embolism and thrombosis of iliac vein, bilateral I Chronic embolism and thrombosis of right popliteal vein I Chronic embolism and thrombosis of left popliteal vein I Chronic embolism and thrombosis of popliteal vein, bilateral I Chronic embolism and thrombosis of right tibial vein I Chronic embolism and thrombosis of left tibial vein I Chronic embolism and thrombosis of tibial vein, bilateral I Chronic embolism and thrombosis of other specified deep vein of right lower extremity I Chronic embolism and thrombosis of other specified deep vein of left lower extremity I Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I Acute embolism and thrombosis of superficial veins of right upper extremity I Acute embolism and thrombosis of superficial veins of left upper extremity I Acute embolism and thrombosis of superficial veins of upper extremity, bilateral I Acute embolism and thrombosis of deep veins of right upper extremity I Acute embolism and thrombosis of deep veins of left upper extremity I Acute embolism and thrombosis of deep veins of upper extremity, bilateral I Chronic embolism and thrombosis of superficial veins of right upper extremity I Chronic embolism and thrombosis of superficial veins of left upper extremity

12 I Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral I Chronic embolism and thrombosis of deep veins of right upper extremity I Chronic embolism and thrombosis of deep veins of left upper extremity I Chronic embolism and thrombosis of deep veins of upper extremity, bilateral I82.A11 Acute embolism and thrombosis of right axillary vein I82.A12 Acute embolism and thrombosis of left axillary vein I82.A13 Acute embolism and thrombosis of axillary vein, bilateral I82.A21 Chronic embolism and thrombosis of right axillary vein I82.A22 Chronic embolism and thrombosis of left axillary vein I82.A23 Chronic embolism and thrombosis of axillary vein, bilateral I82.B11 Acute embolism and thrombosis of right subclavian vein I82.B12 Acute embolism and thrombosis of left subclavian vein I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral I82.B21 Chronic embolism and thrombosis of right subclavian vein I82.B22 Chronic embolism and thrombosis of left subclavian vein I82.B23 Chronic embolism and thrombosis of subclavian vein, bilateral I82.C11 Acute embolism and thrombosis of right internal jugular vein I82.C12 Acute embolism and thrombosis of left internal jugular vein I82.C13 Acute embolism and thrombosis of internal jugular vein, bilateral I82.C21 Chronic embolism and thrombosis of right internal jugular vein I82.C22 Chronic embolism and thrombosis of left internal jugular vein I82.C23 Chronic embolism and thrombosis of internal jugular vein, bilateral I Embolism and thrombosis of superficial veins of right lower extremities I Embolism and thrombosis of superficial veins of left lower extremities I Embolism and thrombosis of superficial veins of lower extremities, bilateral I Acute embolism and thrombosis of other specified veins I Chronic embolism and thrombosis of other specified veins I Varicose veins of right lower extremity with ulcer of thigh I Varicose veins of right lower extremity with ulcer of calf I Varicose veins of right lower extremity with ulcer of ankle I Varicose veins of right lower extremity with ulcer of heel and midfoot I Varicose veins of right lower extremity with ulcer other part of foot I Varicose veins of right lower extremity with ulcer other part of lower leg I Varicose veins of left lower extremity with ulcer of thigh I Varicose veins of left lower extremity with ulcer of calf I Varicose veins of left lower extremity with ulcer of ankle I Varicose veins of left lower extremity with ulcer of heel and midfoot I Varicose veins of left lower extremity with ulcer other part of foot I Varicose veins of left lower extremity with ulcer other part of lower leg I83.11 Varicose veins of right lower extremity with inflammation I83.12 Varicose veins of left lower extremity with inflammation I Varicose veins of right lower extremity with both ulcer of thigh and inflammation

13 I Varicose veins of right lower extremity with both ulcer of calf and inflammation I Varicose veins of right lower extremity with both ulcer of ankle and inflammation I Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of right lower extremity with both ulcer other part of foot and inflammation I Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of left lower extremity with both ulcer of thigh and inflammation I Varicose veins of left lower extremity with both ulcer of calf and inflammation I Varicose veins of left lower extremity with both ulcer of ankle and inflammation I Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of right lower extremities with pain I Varicose veins of left lower extremities with pain I Varicose veins of bilateral lower extremities with pain I Varicose veins of right lower extremities with other complications I Varicose veins of left lower extremities with other complications I Varicose veins of bilateral lower extremities with other complications I83.91 Asymptomatic varicose veins of right lower extremity I83.92 Asymptomatic varicose veins of left lower extremity I83.93 Asymptomatic varicose veins of bilateral lower extremities I Postthrombotic syndrome without complications of right lower extremity I Postthrombotic syndrome without complications of left lower extremity I Postthrombotic syndrome without complications of bilateral lower extremity I Postthrombotic syndrome with ulcer of right lower extremity I Postthrombotic syndrome with ulcer of left lower extremity I Postthrombotic syndrome with ulcer of bilateral lower extremity I Postthrombotic syndrome with inflammation of right lower extremity I Postthrombotic syndrome with inflammation of left lower extremity I Postthrombotic syndrome with inflammation of bilateral lower extremity I Postthrombotic syndrome with ulcer and inflammation of right lower extremity I Postthrombotic syndrome with ulcer and inflammation of left lower extremity I Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity I Postthrombotic syndrome with other complications of right lower extremity I Postthrombotic syndrome with other complications of left lower extremity I Postthrombotic syndrome with other complications of bilateral lower extremity I87.1 Compression of vein

14 I87.2 Venous insufficiency (chronic) (peripheral) I Chronic venous hypertension (idiopathic) without complications of right lower extremity I Chronic venous hypertension (idiopathic) without complications of left lower extremity I Chronic venous hypertension (idiopathic) without complications of bilateral lower extremity I Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I Chronic venous hypertension (idiopathic) with other complications of right lower extremity I Chronic venous hypertension (idiopathic) with other complications of left lower extremity I Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity I87.8 Other specified disorders of veins I96 Gangrene, not elsewhere classified I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac catheterization I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac bypass I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other circulatory system procedure I97.42 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other procedure I97.51 Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure I97.52 Accidental puncture and laceration of a circulatory system organ or structure during other procedure I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following a cardiac catheterization

15 I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following cardiac bypass I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other circulatory system procedure I97.62 Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia L76.01 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating a dermatologic procedure L76.02 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating other procedure L76.11 Accidental puncture and laceration of skin and subcutaneous tissue during a dermatologic procedure L76.12 Accidental puncture and laceration of skin and subcutaneous tissue during other procedure L76.21 Postprocedural hemorrhage and hematoma of skin and subcutaneous tissue following a dermatologic procedure L76.22 Postprocedural hemorrhage and hematoma of skin and subcutaneous tissue following other procedure L Non-pressure chronic ulcer of right thigh limited to breakdown of skin L Non-pressure chronic ulcer of right thigh with fat layer exposed L Non-pressure chronic ulcer of right thigh with necrosis of muscle L Non-pressure chronic ulcer of right thigh with necrosis of bone L Non-pressure chronic ulcer of left thigh limited to breakdown of skin L Non-pressure chronic ulcer of left thigh with fat layer exposed L Non-pressure chronic ulcer of left thigh with necrosis of muscle L Non-pressure chronic ulcer of left thigh with necrosis of bone L Non-pressure chronic ulcer of right calf limited to breakdown of skin L Non-pressure chronic ulcer of right calf with fat layer exposed L Non-pressure chronic ulcer of right calf with necrosis of muscle L Non-pressure chronic ulcer of right calf with necrosis of bone L Non-pressure chronic ulcer of left calf limited to breakdown of skin L Non-pressure chronic ulcer of left calf with fat layer exposed L Non-pressure chronic ulcer of left calf with necrosis of muscle L Non-pressure chronic ulcer of left calf with necrosis of bone L Non-pressure chronic ulcer of right ankle limited to breakdown of skin L Non-pressure chronic ulcer of right ankle with fat layer exposed L Non-pressure chronic ulcer of right ankle with necrosis of muscle L Non-pressure chronic ulcer of right ankle with necrosis of bone L Non-pressure chronic ulcer of left ankle limited to breakdown of skin L Non-pressure chronic ulcer of left ankle with fat layer exposed L Non-pressure chronic ulcer of left ankle with necrosis of muscle

16 L Non-pressure chronic ulcer of left ankle with necrosis of bone L Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of right foot with fat layer exposed L Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L Non-pressure chronic ulcer of other part of right foot with necrosis of bone L Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of left foot with fat layer exposed L Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L Non-pressure chronic ulcer of other part of left foot with necrosis of bone L Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone M Pain in right arm M Pain in left arm M Pain in right leg M Pain in left leg M Pain in right upper arm M Pain in left upper arm M Pain in right forearm M Pain in left forearm M Pain in right hand M Pain in left hand M Pain in right thigh M Pain in left thigh M Pain in right lower leg M Pain in left lower leg M Pain in right foot

17 M Pain in left foot M Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating a musculoskeletal system procedure M Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating other procedure M Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletal system procedure M Accidental puncture and laceration of a musculoskeletal structure during other procedure M Postprocedural hemorrhage and hematoma of a musculoskeletal structure following a musculoskeletal system procedure M Postprocedural hemorrhage and hematoma of a musculoskeletal structure following other procedure O22.01 Varicose veins of lower extremity in pregnancy, first trimester O22.02 Varicose veins of lower extremity in pregnancy, second trimester O22.03 Varicose veins of lower extremity in pregnancy, third trimester O22.11 Genital varices in pregnancy, first trimester O22.12 Genital varices in pregnancy, second trimester O22.13 Genital varices in pregnancy, third trimester O22.21 Superficial thrombophlebitis in pregnancy, first trimester O22.22 Superficial thrombophlebitis in pregnancy, second trimester O22.23 Superficial thrombophlebitis in pregnancy, third trimester O22.31 Deep phlebothrombosis in pregnancy, first trimester O22.32 Deep phlebothrombosis in pregnancy, second trimester O22.33 Deep phlebothrombosis in pregnancy, third trimester O86.81 Puerperal septic thrombophlebitis O87.0 Superficial thrombophlebitis in the puerperium O87.4 Varicose veins of lower extremity in the puerperium Q27.31 Arteriovenous malformation of vessel of upper limb Q27.32 Arteriovenous malformation of vessel of lower limb Q27.39 Arteriovenous malformation, other site Q27.8 Other specified congenital malformations of peripheral vascular system R04.2 Hemoptysis R04.89 Hemorrhage from other sites in respiratory passages R06.02 Shortness of breath R07.1 Chest pain on breathing R07.89 Other chest pain R09.02 Hypoxemia R22.31 Localized swelling, mass and lump, right upper limb R22.32 Localized swelling, mass and lump, left upper limb R22.33 Localized swelling, mass and lump, upper limb, bilateral R22.41 Localized swelling, mass and lump, right lower limb

18 R22.42 Localized swelling, mass and lump, left lower limb R22.43 Localized swelling, mass and lump, lower limb, bilateral R60.0 Localized edema S35.514D Injury of right iliac vein, subsequent S35.515D Injury of left iliac vein, subsequent S35.59XD Injury of other iliac blood vessels, subsequent S45.211A Laceration of axillary or brachial vein, right side, initial S45.211D Laceration of axillary or brachial vein, right side, subsequent S45.212A Laceration of axillary or brachial vein, left side, initial S45.212D Laceration of axillary or brachial vein, left side, subsequent S45.291A Other specified injury of axillary or brachial vein, right side, initial S45.291D Other specified injury of axillary or brachial vein, right side, subsequent S45.292A Other specified injury of axillary or brachial vein, left side, initial S45.292D Other specified injury of axillary or brachial vein, left side, subsequent S45.311A Laceration of superficial vein at shoulder and upper arm level, right arm, initial S45.311D Laceration of superficial vein at shoulder and upper arm level, right arm, subsequent S45.312A Laceration of superficial vein at shoulder and upper arm level, left arm, initial S45.312D Laceration of superficial vein at shoulder and upper arm level, left arm, subsequent S45.391A Other specified injury of superficial vein at shoulder and upper arm level, right arm, initial S45.391D Other specified injury of superficial vein at shoulder and upper arm level, right arm, subsequent S45.392A Other specified injury of superficial vein at shoulder and upper arm level, left arm, initial S45.392D Other specified injury of superficial vein at shoulder and upper arm level, left arm, subsequent S55.211A Laceration of vein at forearm level, right arm, initial S55.211D Laceration of vein at forearm level, right arm, subsequent S55.212A Laceration of vein at forearm level, left arm, initial S55.212D Laceration of vein at forearm level, left arm, subsequent S55.291A Other specified injury of vein at forearm level, right arm, initial S55.291D Other specified injury of vein at forearm level, right arm, subsequent S55.292A Other specified injury of vein at forearm level, left arm, initial S55.292D Other specified injury of vein at forearm level, left arm, subsequent S75.111A Minor laceration of femoral vein at hip and thigh level, right leg, initial S75.111D Minor laceration of femoral vein at hip and thigh level, right leg, subsequent S75.112A Minor laceration of femoral vein at hip and thigh level, left leg, initial

19 S75.112D S75.121A S75.121D S75.122A S75.122D S75.191A S75.191D S75.192A S75.192D S75.211A S75.211D S75.212A S75.212D S75.221A S75.221D S75.222A S75.222D S75.291A S75.291D S75.292A S75.292D S85.311A S85.311D S85.312A Minor laceration of femoral vein at hip and thigh level, left leg, subsequent Major laceration of femoral vein at hip and thigh level, right leg, initial Major laceration of femoral vein at hip and thigh level, right leg, subsequent Major laceration of femoral vein at hip and thigh level, left leg, initial Major laceration of femoral vein at hip and thigh level, left leg, subsequent Other specified injury of femoral vein at hip and thigh level, right leg, initial Other specified injury of femoral vein at hip and thigh level, right leg, subsequent Other specified injury of femoral vein at hip and thigh level, left leg, initial Other specified injury of femoral vein at hip and thigh level, left leg, subsequent Minor laceration of greater saphenous vein at hip and thigh level, right leg, initial Minor laceration of greater saphenous vein at hip and thigh level, right leg, subsequent Minor laceration of greater saphenous vein at hip and thigh level, left leg, initial Minor laceration of greater saphenous vein at hip and thigh level, left leg, subsequent Major laceration of greater saphenous vein at hip and thigh level, right leg, initial Major laceration of greater saphenous vein at hip and thigh level, right leg, subsequent Major laceration of greater saphenous vein at hip and thigh level, left leg, initial Major laceration of greater saphenous vein at hip and thigh level, left leg, subsequent Other specified injury of greater saphenous vein at hip and thigh level, right leg, initial Other specified injury of greater saphenous vein at hip and thigh level, right leg, subsequent Other specified injury of greater saphenous vein at hip and thigh level, left leg, initial Other specified injury of greater saphenous vein at hip and thigh level, left leg, subsequent Laceration of greater saphenous vein at lower leg level, right leg, initial Laceration of greater saphenous vein at lower leg level, right leg, subsequent Laceration of greater saphenous vein at lower leg level, left leg, initial

20 S85.312D Laceration of greater saphenous vein at lower leg level, left leg, subsequent S85.391A Other specified injury of greater saphenous vein at lower leg level, right leg, initial S85.391D Other specified injury of greater saphenous vein at lower leg level, right leg, subsequent S85.392A Other specified injury of greater saphenous vein at lower leg level, left leg, initial S85.392D Other specified injury of greater saphenous vein at lower leg level, left leg, subsequent S85.411A Laceration of lesser saphenous vein at lower leg level, right leg, initial S85.411D Laceration of lesser saphenous vein at lower leg level, right leg, subsequent S85.412A Laceration of lesser saphenous vein at lower leg level, left leg, initial S85.412D Laceration of lesser saphenous vein at lower leg level, left leg, subsequent S85.491A Other specified injury of lesser saphenous vein at lower leg level, right leg, initial S85.491D Other specified injury of lesser saphenous vein at lower leg level, right leg, subsequent S85.492A Other specified injury of lesser saphenous vein at lower leg level, left leg, initial S85.492D Other specified injury of lesser saphenous vein at lower leg level, left leg, subsequent S85.511A Laceration of popliteal vein, right leg, initial S85.511D Laceration of popliteal vein, right leg, subsequent S85.512A Laceration of popliteal vein, left leg, initial S85.512D Laceration of popliteal vein, left leg, subsequent S85.591A Other specified injury of popliteal vein, right leg, initial S85.591D Other specified injury of popliteal vein, right leg, subsequent S85.592A Other specified injury of popliteal vein, left leg, initial S85.592D Other specified injury of popliteal vein, left leg, subsequent S95.211A Laceration of dorsal vein of right foot, initial S95.211D Laceration of dorsal vein of right foot, subsequent S95.212A Laceration of dorsal vein of left foot, initial S95.212D Laceration of dorsal vein of left foot, subsequent S95.291A Other specified injury of dorsal vein of right foot, initial S95.291D Other specified injury of dorsal vein of right foot, subsequent S95.292A Other specified injury of dorsal vein of left foot, initial S95.292D Other specified injury of dorsal vein of left foot, subsequent T38.4X5D Adverse effect of oral contraceptives, subsequent T38.5X5D Adverse effect of other estrogens and progestogens, subsequent

21 Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, T45.7X5D subsequent T79.0XXD Air embolism (traumatic), subsequent T79.1XXD Fat embolism (traumatic), subsequent T79.A11D Traumatic compartment syndrome of right upper extremity, subsequent T79.A12D Traumatic compartment syndrome of left upper extremity, subsequent T79.A21D Traumatic compartment syndrome of right lower extremity, subsequent T79.A22D Traumatic compartment syndrome of left lower extremity, subsequent T79.A3XD Traumatic compartment syndrome of abdomen, subsequent T79.A9XD Traumatic compartment syndrome of other sites, subsequent Air embolism following infusion, transfusion and therapeutic injection, initial T80.0XXA Air embolism following infusion, transfusion and therapeutic injection, subsequent T80.0XXD Vascular complications following infusion, transfusion and therapeutic injection, T80.1XXA initial Vascular complications following infusion, transfusion and therapeutic injection, T80.1XXD subsequent T80.810D Extravasation of vesicant antineoplastic chemotherapy, subsequent T80.818D Extravasation of other vesicant agent, subsequent Other complications following infusion, transfusion and therapeutic injection, T80.89XD subsequent Disruption of external operation (surgical) wound, not elsewhere classified, T81.31XD subsequent Disruption of internal operation (surgical) wound, not elsewhere classified, T81.32XD subsequent T81.33XD Disruption of traumatic injury wound repair, subsequent T81.4XXD Infection following a procedure, subsequent T82.318A Breakdown (mechanical) of other vascular grafts, initial T82.318D Breakdown (mechanical) of other vascular grafts, subsequent T82.328A Displacement of other vascular grafts, initial T82.328D Displacement of other vascular grafts, subsequent T82.338A Leakage of other vascular grafts, initial T82.338D Leakage of other vascular grafts, subsequent T82.398A Other mechanical complication of other vascular grafts, initial T82.398D Other mechanical complication of other vascular grafts, subsequent T82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial T82.41XD Breakdown (mechanical) of vascular dialysis catheter, subsequent T82.42XA Displacement of vascular dialysis catheter, initial T82.42XD Displacement of vascular dialysis catheter, subsequent T82.43XA Leakage of vascular dialysis catheter, initial T82.43XD Leakage of vascular dialysis catheter, subsequent T82.49XA Other complication of vascular dialysis catheter, initial

22 T82.49XD Other complication of vascular dialysis catheter, subsequent Breakdown (mechanical) of surgically created arteriovenous fistula, initial T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, subsequent T82.510D Breakdown (mechanical) of surgically created arteriovenous shunt, initial T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, subsequent T82.511D T82.520A Displacement of surgically created arteriovenous fistula, initial T82.520D Displacement of surgically created arteriovenous fistula, subsequent T82.521A Displacement of surgically created arteriovenous shunt, initial T82.521D Displacement of surgically created arteriovenous shunt, subsequent T82.523A Displacement of balloon (counterpulsation) device, initial T82.523D Displacement of balloon (counterpulsation) device, subsequent T82.524A Displacement of infusion catheter, initial T82.524D Displacement of infusion catheter, subsequent T82.525A Displacement of umbrella device, initial T82.525D Displacement of umbrella device, subsequent T82.528A Displacement of other cardiac and vascular devices and implants, initial Displacement of other cardiac and vascular devices and implants, subsequent T82.528D T82.530A Leakage of surgically created arteriovenous fistula, initial T82.530D Leakage of surgically created arteriovenous fistula, subsequent T82.531A Leakage of surgically created arteriovenous shunt, initial T82.531D Leakage of surgically created arteriovenous shunt, subsequent T82.817A Embolism of cardiac prosthetic devices, implants and grafts, initial T82.817D Embolism of cardiac prosthetic devices, implants and grafts, subsequent T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial T82.818D Embolism of vascular prosthetic devices, implants and grafts, subsequent T82.858A Stenosis of vascular prosthetic devices, implants and grafts, initial T82.858D Stenosis of vascular prosthetic devices, implants and grafts, subsequent Thrombosis of cardiac prosthetic devices, implants and grafts, subsequent T82.867D T82.868A Thrombosis of vascular prosthetic devices, implants and grafts, initial Thrombosis of vascular prosthetic devices, implants and grafts, subsequent T82.868D Embolism due to internal prosthetic devices, implants and grafts, not elsewhere T85.81XD classified, subsequent Thrombosis due to internal prosthetic devices, implants and grafts, not elsewhere T85.86XD classified, subsequent Z Encounter for other preprocedural examination Z Personal history of pulmonary embolism