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

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 2002-2014 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

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 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 beneficiary s 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. 100-02 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 100-03 Medicare National Coverage Determinations (NCD) Manual, Chapter 1 Coverage Determinations Part 1, Section 20.14 Plethysmography and Part 4, Sections 220.5 - Ultrasound Diagnostic Procedures, 220.11 Thermography, and 300.1 - Obsolete or Unreliable Diagnostic Tests. CMS Pub 100-04 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 180 - 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 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. 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

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

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.

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.,

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.

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.

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 93965 TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY) DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO 93970 COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO 93971 COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, 93990 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

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 I80.211 Phlebitis and thrombophlebitis of right iliac vein I80.212 Phlebitis and thrombophlebitis of left iliac vein I80.213 Phlebitis and thrombophlebitis of iliac vein, bilateral I80.221 Phlebitis and thrombophlebitis of right popliteal vein I80.222 Phlebitis and thrombophlebitis of left popliteal vein I80.223 Phlebitis and thrombophlebitis of popliteal vein, bilateral I80.231 Phlebitis and thrombophlebitis of right tibial vein I80.232 Phlebitis and thrombophlebitis of left tibial vein I80.233 Phlebitis and thrombophlebitis of tibial vein, bilateral I80.291 Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I80.292 Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I80.293 Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.8 Phlebitis and thrombophlebitis of other sites I82.1 Thrombophlebitis migrans I82.210 Acute embolism and thrombosis of superior vena cava I82.211 Chronic embolism and thrombosis of superior vena cava I82.290 Acute embolism and thrombosis of other thoracic veins I82.291 Chronic embolism and thrombosis of other thoracic veins I82.411 Acute embolism and thrombosis of right femoral vein I82.412 Acute embolism and thrombosis of left femoral vein

I82.413 Acute embolism and thrombosis of femoral vein, bilateral I82.421 Acute embolism and thrombosis of right iliac vein I82.422 Acute embolism and thrombosis of left iliac vein I82.423 Acute embolism and thrombosis of iliac vein, bilateral I82.431 Acute embolism and thrombosis of right popliteal vein I82.432 Acute embolism and thrombosis of left popliteal vein I82.433 Acute embolism and thrombosis of popliteal vein, bilateral I82.441 Acute embolism and thrombosis of right tibial vein I82.442 Acute embolism and thrombosis of left tibial vein I82.443 Acute embolism and thrombosis of tibial vein, bilateral I82.491 Acute embolism and thrombosis of other specified deep vein of right lower extremity I82.492 Acute embolism and thrombosis of other specified deep vein of left lower extremity I82.493 Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.511 Chronic embolism and thrombosis of right femoral vein I82.512 Chronic embolism and thrombosis of left femoral vein I82.513 Chronic embolism and thrombosis of femoral vein, bilateral I82.521 Chronic embolism and thrombosis of right iliac vein I82.522 Chronic embolism and thrombosis of left iliac vein I82.523 Chronic embolism and thrombosis of iliac vein, bilateral I82.531 Chronic embolism and thrombosis of right popliteal vein I82.532 Chronic embolism and thrombosis of left popliteal vein I82.533 Chronic embolism and thrombosis of popliteal vein, bilateral I82.541 Chronic embolism and thrombosis of right tibial vein I82.542 Chronic embolism and thrombosis of left tibial vein I82.543 Chronic embolism and thrombosis of tibial vein, bilateral I82.591 Chronic embolism and thrombosis of other specified deep vein of right lower extremity I82.592 Chronic embolism and thrombosis of other specified deep vein of left lower extremity I82.593 Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I82.611 Acute embolism and thrombosis of superficial veins of right upper extremity I82.612 Acute embolism and thrombosis of superficial veins of left upper extremity I82.613 Acute embolism and thrombosis of superficial veins of upper extremity, bilateral I82.621 Acute embolism and thrombosis of deep veins of right upper extremity I82.622 Acute embolism and thrombosis of deep veins of left upper extremity I82.623 Acute embolism and thrombosis of deep veins of upper extremity, bilateral I82.711 Chronic embolism and thrombosis of superficial veins of right upper extremity I82.712 Chronic embolism and thrombosis of superficial veins of left upper extremity

I82.713 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral I82.721 Chronic embolism and thrombosis of deep veins of right upper extremity I82.722 Chronic embolism and thrombosis of deep veins of left upper extremity I82.723 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 I82.811 Embolism and thrombosis of superficial veins of right lower extremities I82.812 Embolism and thrombosis of superficial veins of left lower extremities I82.813 Embolism and thrombosis of superficial veins of lower extremities, bilateral I82.890 Acute embolism and thrombosis of other specified veins I82.891 Chronic embolism and thrombosis of other specified veins I83.011 Varicose veins of right lower extremity with ulcer of thigh I83.012 Varicose veins of right lower extremity with ulcer of calf I83.013 Varicose veins of right lower extremity with ulcer of ankle I83.014 Varicose veins of right lower extremity with ulcer of heel and midfoot I83.015 Varicose veins of right lower extremity with ulcer other part of foot I83.018 Varicose veins of right lower extremity with ulcer other part of lower leg I83.021 Varicose veins of left lower extremity with ulcer of thigh I83.022 Varicose veins of left lower extremity with ulcer of calf I83.023 Varicose veins of left lower extremity with ulcer of ankle I83.024 Varicose veins of left lower extremity with ulcer of heel and midfoot I83.025 Varicose veins of left lower extremity with ulcer other part of foot I83.028 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 I83.211 Varicose veins of right lower extremity with both ulcer of thigh and inflammation

I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation I83.214 Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I83.215 Varicose veins of right lower extremity with both ulcer other part of foot and inflammation I83.218 Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I83.221 Varicose veins of left lower extremity with both ulcer of thigh and inflammation I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation I83.224 Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I83.225 Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I83.228 Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I83.811 Varicose veins of right lower extremities with pain I83.812 Varicose veins of left lower extremities with pain I83.813 Varicose veins of bilateral lower extremities with pain I83.891 Varicose veins of right lower extremities with other complications I83.892 Varicose veins of left lower extremities with other complications I83.893 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 I87.001 Postthrombotic syndrome without complications of right lower extremity I87.002 Postthrombotic syndrome without complications of left lower extremity I87.003 Postthrombotic syndrome without complications of bilateral lower extremity I87.011 Postthrombotic syndrome with ulcer of right lower extremity I87.012 Postthrombotic syndrome with ulcer of left lower extremity I87.013 Postthrombotic syndrome with ulcer of bilateral lower extremity I87.021 Postthrombotic syndrome with inflammation of right lower extremity I87.022 Postthrombotic syndrome with inflammation of left lower extremity I87.023 Postthrombotic syndrome with inflammation of bilateral lower extremity I87.031 Postthrombotic syndrome with ulcer and inflammation of right lower extremity I87.032 Postthrombotic syndrome with ulcer and inflammation of left lower extremity I87.033 Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity I87.091 Postthrombotic syndrome with other complications of right lower extremity I87.092 Postthrombotic syndrome with other complications of left lower extremity I87.093 Postthrombotic syndrome with other complications of bilateral lower extremity I87.1 Compression of vein

I87.2 Venous insufficiency (chronic) (peripheral) I87.301 Chronic venous hypertension (idiopathic) without complications of right lower extremity I87.302 Chronic venous hypertension (idiopathic) without complications of left lower extremity I87.303 Chronic venous hypertension (idiopathic) without complications of bilateral lower extremity I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I87.321 Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I87.322 Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I87.323 Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity I87.8 Other specified disorders of veins I96 Gangrene, not elsewhere classified I97.410 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac catheterization I97.411 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac bypass I97.418 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 I97.610 Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following a cardiac catheterization

I97.611 Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following cardiac bypass I97.618 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 L97.111 Non-pressure chronic ulcer of right thigh limited to breakdown of skin L97.112 Non-pressure chronic ulcer of right thigh with fat layer exposed L97.113 Non-pressure chronic ulcer of right thigh with necrosis of muscle L97.114 Non-pressure chronic ulcer of right thigh with necrosis of bone L97.121 Non-pressure chronic ulcer of left thigh limited to breakdown of skin L97.122 Non-pressure chronic ulcer of left thigh with fat layer exposed L97.123 Non-pressure chronic ulcer of left thigh with necrosis of muscle L97.124 Non-pressure chronic ulcer of left thigh with necrosis of bone L97.211 Non-pressure chronic ulcer of right calf limited to breakdown of skin L97.212 Non-pressure chronic ulcer of right calf with fat layer exposed L97.213 Non-pressure chronic ulcer of right calf with necrosis of muscle L97.214 Non-pressure chronic ulcer of right calf with necrosis of bone L97.221 Non-pressure chronic ulcer of left calf limited to breakdown of skin L97.222 Non-pressure chronic ulcer of left calf with fat layer exposed L97.223 Non-pressure chronic ulcer of left calf with necrosis of muscle L97.224 Non-pressure chronic ulcer of left calf with necrosis of bone L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin L97.312 Non-pressure chronic ulcer of right ankle with fat layer exposed L97.313 Non-pressure chronic ulcer of right ankle with necrosis of muscle L97.314 Non-pressure chronic ulcer of right ankle with necrosis of bone L97.321 Non-pressure chronic ulcer of left ankle limited to breakdown of skin L97.322 Non-pressure chronic ulcer of left ankle with fat layer exposed L97.323 Non-pressure chronic ulcer of left ankle with necrosis of muscle

L97.324 Non-pressure chronic ulcer of left ankle with necrosis of bone L97.411 Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L97.412 Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L97.413 Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L97.414 Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L97.422 Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L97.424 Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L97.511 Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed L97.513 Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone L97.521 Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L97.522 Non-pressure chronic ulcer of other part of left foot with fat layer exposed L97.523 Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L97.524 Non-pressure chronic ulcer of other part of left foot with necrosis of bone L97.811 Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L97.812 Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L97.813 Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L97.814 Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L97.821 Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L97.822 Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L97.823 Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L97.824 Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone M79.601 Pain in right arm M79.602 Pain in left arm M79.604 Pain in right leg M79.605 Pain in left leg M79.621 Pain in right upper arm M79.622 Pain in left upper arm M79.631 Pain in right forearm M79.632 Pain in left forearm M79.641 Pain in right hand M79.642 Pain in left hand M79.651 Pain in right thigh M79.652 Pain in left thigh M79.661 Pain in right lower leg M79.662 Pain in left lower leg M79.671 Pain in right foot

M79.672 Pain in left foot M96.810 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating a musculoskeletal system procedure M96.811 Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating other procedure M96.820 Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletal system procedure M96.821 Accidental puncture and laceration of a musculoskeletal structure during other procedure M96.830 Postprocedural hemorrhage and hematoma of a musculoskeletal structure following a musculoskeletal system procedure M96.831 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

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

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

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

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

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 Z01.818 Encounter for other preprocedural examination Z86.711 Personal history of pulmonary embolism

Z86.718 Personal history of other venous thrombosis and embolism Z86.72 Personal history of thrombophlebitis Z86.74 Personal history of sudden cardiac arrest Showing 1 to 451 of 451 entries in Group 1 Group 2 Paragraph: Hemodialysis Access Examination (93990) For codes in the table below that require a 7th character, letter A initial, D subsequent or S sequela may be used. Group 2Codes ICD-10 Code Description I77.0 Arteriovenous fistula, acquired N18.6 End stage renal disease T82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial T82.42XA Displacement of vascular dialysis catheter, initial T82.43XA Leakage of vascular dialysis catheter, initial T82.49XA Other complication of vascular dialysis catheter, initial T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial T82.520A Displacement of surgically created arteriovenous fistula, initial T82.530A Leakage of surgically created arteriovenous fistula, initial T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial Infection and inflammatory reaction due to other cardiac and vascular devices, T82.7XXA implants and grafts, initial T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial T82.828A Fibrosis of vascular prosthetic devices, implants and grafts, initial T82.838A Hemorrhage of vascular prosthetic devices, implants and grafts, initial T82.848A Pain from vascular prosthetic devices, implants and grafts, initial T82.858A Stenosis of vascular prosthetic devices, implants and grafts, initial T82.868A Thrombosis of vascular prosthetic devices, implants and grafts, initial T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial Z99.2 Dependence on renal dialysis Showing 1 to 19 of 19 entries in Group 2 Group 3 Paragraph: Vessel Mapping for Vessels for Hemodialysis Access (G0365) Pre-operative examination for potential harvest vein grafts or pre-operative examination of

vessel prior to hemodialysis access surgery Z01.818. For codes in the table below that require a 7th character, letter A initial, D subsequent or S sequela may be used. Group 3Codes ICD-10 Code Description I74.2 Embolism and thrombosis of arteries of the upper extremities N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease T82.42XA Displacement of vascular dialysis catheter, initial T82.43XA Leakage of vascular dialysis catheter, initial T82.49XA Other complication of vascular dialysis catheter, initial T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial T82.520A Displacement of surgically created arteriovenous fistula, initial T82.530A Leakage of surgically created arteriovenous fistula, initial T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial Infection and inflammatory reaction due to other cardiac and vascular devices, T82.7XXA implants and grafts, initial T82.818A Embolism of vascular prosthetic devices, implants and grafts, initial T82.828A Fibrosis of vascular prosthetic devices, implants and grafts, initial T82.838A Hemorrhage of vascular prosthetic devices, implants and grafts, initial T82.848A Pain from vascular prosthetic devices, implants and grafts, initial T82.858A Stenosis of vascular prosthetic devices, implants and grafts, initial T82.868A Thrombosis of vascular prosthetic devices, implants and grafts, initial T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial Z01.818 Encounter for other preprocedural examination Showing 1 to 21 of 21 entries in Group 3 ICD-10 Codes that DO NOT Support Medical Necessity Group 1 Paragraph: N/A Group 1 Codes: N/A

Additional ICD-10 Information N/A General Information Associated Information 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 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 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. 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.

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 veinmapping 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 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 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. Preventive and/or screening services unless covered in Statute are not covered by Medicare. Sources of Information and Basis for Decision ACR. (2010, Amended 2014). ACR-AIUM-SRU Practice parameter for the performance of peripheral venous ultrasound exam. American College of Radiology Practice Parameter. Resolution 39. pp.1-8. Accessed 04/28/2015. ACR. (2011, Amended 2014). ACR-AIUM-SRU Practice parameter for the performance of ultrasound vascular mapping for the preoperative planning of dialysis access. American College of Radiology Practice Parameter. Resolution 39. pp.1-7. Accessed 04/28/2015. ACR. (2011, Amended 2014). ACR-SPR-SRU Practice parameter for performing and interpreting diagnostic ultrasound examinations. American College of Radiology. Resolution 39. pp.1-6. Accessed 04/28/2015. ACR. (Revised 2014). ACR Practice parameter for communication of diagnostic imaging findings. American College of Radiology Practice Parameter. Resolution 11. pp.1-9. Accessed 04/28/2015.

ACR. (Revised 2011). ACR Technical standard for diagnostic medical physics performance monitoring of real time ultrasound equipment. American College of Radiology Practice Parameter. Resolution 3. pp.1-7. Accessed 04/20/2015. ACR. (2010, Sep 9). Ultrasound accreditation program requirements. American College of Radiology. pp.1-10. Accessed 04/20/2015. Allon, J., Lockhart, M.E., Lilly, R.Z., & et al. (2001). Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney International, 60:2013-2020. Accessed 04/28/2015 Erickson, CA., & et al. (1996, Jan). Ongoing vascular laboratory surveillance is essential to maximize long-term in situ saphenous vein bypass patency. Journal of Vascular Surgery. 23(1):18-27. Accessed 04/28/2015. Ferring, M., Henderson, J., Wilmink, A., & Smith, S. (2008). Vascular ultrasound for the preoperative evaluation prior to arteriovenous fistula formation for hemodialysis: Review of the evidence. Nephrology Dialysis Transplantation, 23(6):1809-1815. Accessed 04/28/2015 Gerhard-Herman, M., Gardin, JM., Jaff, M., Mohler, E., Roman, M., & Naqvi, TZ. (2006, Aug). Guidelines for noninvasive laboratory testing: a report from the American Society of e Echocardiography and the Society of Vascular Medicine and Biology. Journal of the American Society of Echocardiography. 19(8):955-972. Accessed 04/28/2015. Intersocietal Accreditation Commission. (2013, Jun 15). IAC Standards and Guidelines for Vascular Testing Accreditation. Page 1-67. Accessed 04/20/2015. National Kidney Foundation (2006). KDOQI clinical practice guidelines and recommendations: hemodialysis adequacy, peritoneal dialysis adequacy, vascular access. Accessed 04/28/2015. Silva, M. B., Hobson, R. W., Pappas, P. J., & et al. (1997, Jun). A strategy for increasing use of autogenous hemodialysis access procedure: Impact of preoperative noninvasive evaluation. Journal of Vascular Surgery, 27(2):302-308. Accessed 04/28/2015. Teodorescu, V., Gustavson, S., & Schanzer, H. (2012, Jun). Duplex ultrasound evaluation of hemodialysis access: A detailed protocol. International Journal of Nephrology. 2012(article no. 508956):1-7. Accessed 04/28/2015. Contractor Advisory Committee (CAC) Meeting Meeting Date Meeting Information 02/05/2015 Iowa, Kansas, Missouri, Nebraska 02/04/2015 Indiana, Michigan 0/27/2015 Open Meeting

Start Date of Comment Period 02/05/2015 End Date of Comment Period 03/21/2015 Revision History Information N/A Associated Documents Attachments Billing and Coding Guidelines (PDF - 66 KB ) Related Local Coverage Documents Article(s) A54400 - Response to Comments: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies Related National Coverage Documents NCD(s) 300.1 - Obsolete or Unreliable Diagnostic Tests 20.14 - Plethysmography 220.11 - Thermography 220.5 - Ultrasound Diagnostic Procedures Public Version(s) Updated on 06/16/2015 with effective dates 10/01/2015 - N/A National Coverage Determination (NCD) for Obsolete or Unreliable Diagnostic Tests (300.1) Tracking Information Publication Number Manual Section Number 100-3 300.1 Manual Section Title Obsolete or Unreliable Diagnostic Tests

Version Number 2 Implementation Date Effective Date of this Version 6/19/2006 6/19/2006 Description Information Benefit Category Diagnostic Tests (other) Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Indications and Limitations of Coverage A. Diagnostic Tests Do not routinely pay for the following diagnostic tests because they are obsolete and have been replaced by more advanced procedures. The listed tests may be paid for only if the medical need for the procedure is satisfactorily justified by the physician who performs it. When the services are subject to the Quality Improvement Organization (QIO) Review, the QIO is responsible for determining that satisfactory medical justification exists. When the services are not subject to QIO review, the A/B Medicare Administrative Contractor is responsible for determining that satisfactory medical justification exists. This includes: Amylase, blood isoenzymes, electrophoretic, Chromium, blood, Guanase, blood, Zinc sulphate turbidity, blood, Skin test, cat scratch fever, Skin test, lymphopathia venereum, Circulation time, one test, Cephalin flocculation, Congo red, blood, Hormones, adrenocorticotropin quantitative animal tests, Hormones, adrenocorticotropin quantitative bioassay, Thymol turbidity, blood, Skin test, actinomycosis, Skin test, brucellosis, Skin test, psittacosis, Skin test, trichinosis, Calcium, feces, 24-hour quantitative, Starch, feces, screening,

Chymotrypsin, duodenal contents, Gastric analysis, pepsin, Gastric analysis, tubeless, Calcium saturation clotting time, Capillary fragility test (Rumpel-Leede), Colloidal gold, Bendien's test for cancer and tuberculosis, Bolen's test for cancer, Rehfuss test for gastric acidity, and Serum seromucoid assay for cancer and other diseases. B. Cardiovascular Tests Do not pay for the following phonocardiography and vectorcardiography diagnostic tests because they have been determined to be outmoded and of little clinical value. They include: Phonocardiogram with or without ECG lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician), Phonocardiogram; tracing only, without interpretation and report (e.g., when equipment is supplied by the hospital, clinic), Phonocardiogram; interpretation and report, Phonocardiogram with ECG lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report, Phonocardiogram; without interpretation and report, Phonocardiogram; interpretation and report only, Intracardiac, Vectorcardiogram (VCG), with or without ECG; with interpretation and report, Vectorcardiogram; tracing only, without interpretation and report, and, Vectorcardiogram; interpretation and report only. Transmittal Information Transmittal Number 48 Coverage Transmittal Link http://www.cms.gov/transmittals/downloads/r48ncd.pdf Revision History 04/01/1997 - Excluded coverage of 10 phonocardiography and vectorcardiography diagnostic tests. Effective 1/1/1997. (TN 96)

03/2006 - Delete coding information. Effective/Implementation date: 06/19/2006. (TN 48 ) (CR4278) Additional Information Other Versions Obsolete or Unreliable Diagnostic Tests - Version 1, Effective between 1/1/1997-6/19/2006 National Coverage Determination (NCD) for Plethysmography (20.14) Tracking Information Publication Number Manual Section Number 100-3 20.14 Manual Section Title Plethysmography Version Number 1 Effective Date of this Version 11/15/1980 Description Information Benefit Category Diagnostic Tests (other) Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Item/Service Description Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative and postoperative evaluation of peripheral artery disease in the internal medicine or vascular surgery practice. It is also a useful tool for the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patient's candidacy for foot surgery.

The oldest form of plethysmography is the venous occlusive pneumoplethysmography. This method is cumbersome, time consuming, and requires considerable training to give useful, reproducible results. Nonetheless, in the setting of the hospital vascular laboratory, this technique is considered a reasonable and necessary procedure for the diagnostic evaluation of suspected peripheral arterial disease. It is unsuitable for routine use in the physician's office. Recently, however, a number of other plethysmographic methods have been developed which make use of phenomena such as changes in electric impedance or changes in segmental blood pressure at constant volume to assess regional perfusion. Several of these methods have reached a level of development which makes them clinically valuable. Indications and Limitations of Coverage Medicare coverage is extended to those procedures listed in Category I below when used for the accepted medical indications mentioned above. The procedures in Category II are still considered experimental and are not covered at this time. Denial of claims because a noncovered procedure was used or because there was no medical indication for plethysmographic evaluation of any type should be based on 1862(a)(1) of the Act. Category I - Covered 1. Segmental Plethysmography - Included under this procedure are services performed with a regional plethysmograph, differential plethysmograph, recording oscillometer, and a pulse volume recorder. 2. Electrical Impedance Plethysmography 3. Ultrasonic Measurement of Blood Flow (Doppler) - While not strictly a plethysmographic method, this is also a useful tool in the evaluation of suspected peripheral vascular disease or preoperative screening of podiatric patients with suspected peripheral vascular compromise. (See 50-7 for the applicable coverage policy on this procedure.) 4. Oculoplethysmography - See NCD on Noninvasive Tests of Carotid Function, 20.17. 5. Strain Gauge Plethysmography - This test is based on recording the non-pulsatile aspects of inflowing blood at various points on an extremity by a mercury-in-silastic strain gauge sensor. The instrument consists of a chart recorder, an automatic cuff inflation and deflation system, and a recording manometer. Category II - Experimental The following methods have not yet reached a level of development such as to allow their routine use in the evaluation of suspected peripheral vascular disease. 1. Inductance Plethysmography - This method is considered experimental and does not provide reproducible results. 2. Capacitance Plethysmography - This method is considered experimental and does not provide reproducible results.

3. Mechanical Oscillometry - This is a non-standardized method which offers poor sensitivity and is not considered superior to the simple measurement of peripheral blood pressure. 4. Photoelectric Plethysmography - This method is considered useful only in determining whether or not a pulse is present and does not provide reproducible measurements of blood flow. Differential plethysmography, on the other hand, is a system which uses an impedance technique to compare pulse pressures at various points along a limb, with a reference pressure at the mid-brachial or wrist level. It is not clear whether this technique, as usually performed in the physician's office, meets the definition of plethysmography because quantitative measurements of blood flow are usually not made. It has been concluded, in any event, that the differential plethysmography system is a blood pulse recorder of undetermined value, which has the potential for significant overutilization. Therefore, reimbursement for studies done by techniques other than venous occlusive pneumoplethysmography should be denied, at least until additional data on these devices, including controlled clinical studies, become available. National Coverage Determination (NCD) for Thermography (220.11) Tracking Information Publication Number Manual Section Number 100-3 220.11 Manual Section Title Thermography Version Number 1 Effective Date of this Version 12/21/1992 Description Information Benefit Category Diagnostic Tests (other) Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Item/Service Description

Thermography is the measurement of self-emanating infrared radiation that reveals temperature variations at the surface of the body. The thermographic device senses body temperature and demonstrates areas of differing heat emission by producing brightly colored patterns. Each color represents a specific temperature level. Interpretation of these color patterns according to designated anatomic distribution is thought to aid in diagnosing a vast array of diseases. Indications and Limitations of Coverage Thermography for any indication (including breast lesions which were excluded from Medicare coverage on July 20, 1984) is excluded from Medicare coverage because the available evidence does not support this test as a useful aid in the diagnosis or treatment of illness or injury. Therefore, it is not considered effective. This exclusion was published as a CMS Final Notice in the "Federal Register" on November 20, 1992. Transmittal Information Transmittal Number 67 Revision History 02/1994 - Noncovered for all indications. Effective date 12/21/1992. (TN 67) National Coverage Determination (NCD) for Ultrasound Diagnostic Procedures (220.5) Tracking Information Publication Number Manual Section Number 100-3 220.5 Manual Section Title Ultrasound Diagnostic Procedures Version Number 3 Implementation Date Effective Date of this Version 9/28/2007 5/22/2007

Description Information Benefit Category Diagnostic Tests (other) Inpatient Hospital Services Physicians' Services Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. Item/Service Description A. General Ultrasound diagnostic procedures utilizing low energy sound waves are being widely employed to determine the composition and contours of nearly all body tissues except bone and air-filled spaces. This technique permits noninvasive visualization of even the deepest structures in the body. The use of the ultrasound technique is sufficiently developed that it can be considered essential to good patient care in diagnosing a wide variety of conditions. Ultrasound diagnostic procedures are listed below and are divided into two categories. Medicare coverage is extended to the procedures listed in Category I. Periodic claims review by the A/Medicare Administrative Contractor (A/MAC) medical consultants should be conducted to ensure that the techniques are medically appropriate and the general indications specified in these categories are met. Techniques in Category II are considered experimental and should not be covered at this time. Indications and Limitations of Coverage B. Nationally Covered Indications Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and nuclear medicine diagnostic technique) Echoencephalography, (Diencephalic Midline) (A-Mode). Echoencephalography, Complete (Diencephalic Midline and Ventricular Size). Ocular and Orbital Echography (A-Mode). Covered procedures include efforts to determine the suitability of aphakic patients for implantation of an artificial lens (pseudophakoi) following cataract surgery. Ocular and Orbital Sonography (B-Mode). Echocardiography, Pericardial Effusion (M-Mode). Pericardiocentesis, by Ultrasonic Guidance. Echocardiography, Cardiac Valve(s) (M-Mode). Echocardiography, Complete (M-Mode). Echocardiography, limited (e.g., follow-up or limited study) (M-Mode).

Pleural Effusion Echography. Thoracentesis, by Ultrasonic Guidance. Abdominal Sonography, complete survey study (B-Scan). Abdominal Sonography, limited (e.g., follow-up or limited study) (B-Scan). Abdominal Sonography is not synonymous with ultrasound examination of individual organs. Renal Cyst Aspiration, by Ultrasonic Guidance. Renal Biopsy, by Ultrasonic Guidance. Pancreas Sonography (B-Scan). Pancreatic Sonography has proven effective in diagnosing pseudocysts. Spleen Sonography (B-Scan). Abdominal Aorta Echography (A-Mode). Abdominal Aorta Sonography (B-Scan). Retroperitoneal Sonography (B-Scan). Retroperitoneal Sonography does not include planning of fields for radiation therapy. Urinary Bladder Sonography (B-Scan). Urinary bladder Sonography does not include staging of bladder tumors. Pregnancy Diagnosis Sonography (B-Scan). Fetal Age Determination (Biparietal Diameter) Sonography (B-Scan). Fetal Growth Rate Sonography (B-Scan). Placenta Localization Sonography (B-Scan). Pregnancy Sonography, Complete (B-Scan). Molar Pregnancy Diagnosis Sonography (B-Scan). Ectopic Pregnancy Diagnosis Sonography (B-Scan). Passive Testing (Antepartum Monitoring of Fetal Heart Rate In the Resting Fetus). Intrauterine Contraceptive Device Sonography (B-Scan). Pelvic Mass Diagnosis Sonography (B-Scan). Amniocentesis, by Ultrasonic Guidance. Arterial Flow Study, Peripheral (Doppler). Venous Flow Study, Peripheral (Doppler). Arterial Aneurysm, Peripheral (B-Scan). Radiation Therapy Planning Sonography (B-Scan). Thyroid Echography (A-Mode). Thyroid Sonography (B-Scan). Breast Echography (A-Mode). Breast Sonography (B-Scan). Hepatic Sonography (B-Scan). Gallbladder Sonography. Renal Sonography. Two-Dimensional Echocardiography (B-Mode). Monitoring of cardiac output (Esophageal Doppler) for ventilated patients in the ICU and operative patients with a need for intra-operative fluid optimization C. Nationally Non-Covered Indications Category II - (Clinical reliability and efficacy not proven):

B-Scan for atherosclerotic narrowing of peripheral arteries. D. Other Uses for ultrasound diagnostic procedures not listed in Category I or II above are left to local MAC discretion. In view of the rapid changes in the field of ultrasound diagnosis, uses for ultrasound diagnostic procedures other than those listed under Categories I and II should be carefully reviewed before payment. Medical justification may be required. (This NCD last reviewed June 2007.) Cross Reference Cross reference: 20.17 Claims Processing Instructions TN 2472 (Medicare Claims Processing) TN 2743 (Medicare Claims Processing) Transmittal Information Transmittal Number 76 Coverage Transmittal Link http://www.cms.gov/transmittals/downloads/r76ncd.pdf National Coverage Analyses (NCAs) National Coverage Analyses (NCAs) This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database. First reconsideration for Ultrasound Diagnostic Procedures (CAG-00309R) Additional Information Other Versions

Ultrasound Diagnostic Procedures - Version 2, Effective between 5/17/2007-5/22/2007 Ultrasound Diagnostic Procedures - Version 1, Effective between 1/1/1966-5/17/2007

Billing and Coding Guidelines for Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies LCD Database ID Number L35751 Medicare manual excerpts: Ultrasound Diagnostic Procedures CMS Pub100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 4 Section 220.5- Ultrasound Diagnostic Procedures (Rev. 76, 09-28-07). Ultrasound diagnostic procedures are listed below and are divided into two categories. Medicare coverage is extended to the procedures listed in Category I. Periodic claims review by the A/Medicare Administrative Contractor s (A/MAC) medical consultants should be conducted to ensure that the techniques are medically appropriate and the general indications specified in these categories are met. Techniques in Category II are considered experimental and should not be covered at this time. B. Nationally Covered Indications Category I - (Clinically effective, usually part of initial patient evaluation, may be an adjunct to radiologic and nuclear medicine diagnostic technique). Partial list is included see IOM for total list: Venous Flow Study, Peripheral (Doppler) Plethysmography CMS Pub. 100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 1 Section 20.14 -Plethysmography, (Rev. 1, 10-03-03). Plethysmography involves the measurement and recording (by one of several methods) of changes in the size of a body part as modified by the circulation of blood in that part. Plethysmography is of value as a noninvasive technique for diagnostic, preoperative and postoperative evaluation of peripheral artery disease in the internal medicine or vascular surgery practice. It is also a useful tool for the preoperative podiatric evaluation of the diabetic patient or one who has intermittent claudication or other signs or symptoms indicative of peripheral vascular disease which have a bearing on the patient s candidacy for foot surgery. The oldest form of plethysmography is the venous occlusive pneumoplethysmography. This method is cumbersome, time consuming, and requires considerable training to give useful, reproducible results. Nonetheless, in the setting of the hospital vascular laboratory, this technique is considered a reasonable and necessary procedure for the diagnostic evaluation of suspected peripheral arterial disease. It is unsuitable for routine use in the physician s office. Recently, however, a number of other plethysmographic methods have been developed which make use of phenomena such as changes in electric impedance or changes in segmental blood pressure at constant volume to assess regional perfusion. Several of these methods have reached a level of development which makes them clinically valuable.

Medicare coverage is extended to those procedures listed in Category I below when used for the accepted medical indications mentioned above. The procedures in Category II are still considered experimental and are not covered at this time. Denial of claims because a noncovered procedure was used or because there was no medical indication for plethysmographic evaluation of any type should be based on 1862(a) (1) of the Act. Category I Covered Segmental Plethysmography - Included under this procedure are services performed with a regional plethysmograph, differential plethysmograph, recording oscillometer, and a pulse volume recorder. Electrical Impedance Plethysmography - This method senses changes in a minute electric current sent through a portion of the body by means of separate electrodes proximal and distal to the sensing electrodes. Changes in electrical impedance of a limb are a reflection of the change in blood content and limb volume. Ultrasonic Measurement of Blood Flow (Doppler) - While not strictly a plethysmographic method, this is also a useful tool in the evaluation of suspected peripheral vascular disease or preoperative screening of podiatric patients with suspected peripheral vascular compromise. CMS Pub 100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 4 Section 220.5- Ultrasound Diagnostic Procedures (Rev. 76, 09-28-07). Strain Gauge Plethysmography - This test is based on recording the non-pulsatile aspects of inflowing blood at various points on an extremity by a mercury-in-silastic strain gauge sensor. The instrument consists of a chart recorder, automatic cuff inflation and deflation system, and a recording manometer. Category II Experimental The following methods have not yet reached a level of development such as to allow their routine use in the evaluation of suspected peripheral vascular disease and are not covered since they are considered experimental. Inductance Plethysmography - This method is considered experimental and does not provide reproducible results. Capacitance Plethysmography - This method is considered experimental and does not provide reproducible results. Mechanical Oscillometry - This is a non-standardized method which offers poor sensitivity and is not considered superior to the simple measurement of peripheral blood pressure. Photoelectric Plethysmography - This method is considered useful only in determining whether or not a pulse is present and does not provide reproducible measurements of blood flow. Differential plethysmography, on the other hand, is a system which uses an impedance technique to compare pulse pressures at various points along a limb, with a reference pressure at the midbrachial or wrist level. It is not clear whether this technique, as usually performed in the physician s office, meets the definition of plethysmography because quantitative measurements of blood flow are usually not made. It has been concluded, in any event, that the differential plethysmography system is a blood pulse recorder of undetermined value which has the potential for significant overutilization. Therefore, reimbursement for studies done by techniques other

than venous occlusive pneumoplethysmography should be denied, at least until additional data on these devices, including controlled clinical studies, become available. The following studies are not covered: Light reflectance rheography. Thermography CMS Pub.100-03 Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, Part 4 Section 220.11- Thermography, (Rev. 1, 10-03-03). Thermography is the measurement of self-emanating infrared radiation that reveals temperature variations at the surface of the body. The thermographic device senses body temperature and demonstrates areas of differing heat emission by producing brightly colored patterns. Each color represents a specific temperature level. Interpretation of these color patterns according to designated anatomic distribution is thought to aid in diagnosing a vast array of diseases. Thermography for any indication (including breast lesions which were excluded from Medicare coverage on July 20, 1984) is excluded from Medicare coverage because the available evidence does not support this test as a useful aid in the diagnosis or treatment of illness or injury. Therefore, it is not considered effective. This exclusion was published as a CMS Final Notice in the Federal Register on November 20, 1992. Noninvasive Vascular Studies for ESRD Patients CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 11 End Stage Renal Disease, Section 40 Other Services (Rev. 171, Issued: 06-07-13, Effective: 01-01-11, Implementation: 09-09-13). For dialysis to take place there must be a means of access so that the exchange of waste products may occur. As part of the dialysis treatment, ESRD facilities are responsible for monitoring access to determine if the access site is functioning correctly. Procedures associated with monitoring access may include activities such as, but not limited to, taking venous pressure, aspirating thrombus, observing elevated recirculation time, reduced urea reduction ratios, or collapsed shunt, etc. All such procedures are included under the ESRD PPS. Non-invasive vascular studies such as duplex and Doppler flow scans are not covered as separately billable services if used to monitor a patient s vascular access site. An ESRD facility must furnish all necessary services, equipment, and supplies associated with a dialysis treatment, either directly or under arrangements. The ESRD facility is financially responsible for the service. If an ESRD facility or a renal physician decides to monitor the patient s access site with a non-invasive vascular study and does not have the equipment to perform the procedure, the ESRD facility or physician may arrange for the service to be furnished by another source. The alternative source, such as an independent diagnostic testing facility must look to the ESRD facility for payment. Doppler flow studies may be considered appropriate in the presence of signs or symptoms of possible failure of the ESRD patient s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient. Routine monitoring by noninvasive Doppler flow studies is included under the ESRD PPS. Examples supporting the medical necessity for Doppler flow studies include: Elevated dynamic venous pressure >200mm HG when measured during dialysis with the blood pump set on a 200cc/min.

Access recirculation of 12 percent or greater, An otherwise unexplained urea reduction ratio <60 percent, and An access with a palpable water hammer pulse on examination, (which implies venous outflow obstruction). 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. The patient s medical record(s) must provide documentation supporting the need for more than one imaging study. This policy is applicable to claims from ESRD facilities and all other sources, such as independent diagnostic testing facilities and hospital outpatient departments. The professional component of the procedure is included in the MCP. The professional component is denied if billed by the MCP physician. Medically necessary services that are included or bundled into the MCP (e.g., test interpretations) are separately payable when furnished by physicians other than the MCP physician. The MCP physician is identified by the performing provider number that billed MCP services identified by the HCPCS code 90995. Noninvasive Vascular Studies for ESRD Patients Outpatient, Independent Facility, and Physician CMS Pub 100-04 Medicare Claims Processing Manual, Chapter 8 Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, Section 180 - Noninvasive Studies for ESRD Patients - Facility and Physician Services (Rev. 1, 10-01-03). As part of the dialysis treatment, ESRD facilities are responsible for monitoring access, and when occlusions occur, either declot the access or refer the patient for appropriate treatment. ESRD facilities may not monitor access through noninvasive vascular studies such as duplex and Doppler flow scans and bill separately for these procedures. Noninvasive vascular studies are not covered as a separately billable service if used to monitor a patient s vascular access site. Medicare pays for the technical component of the procedure in the composite payment rate. Where there are signs and symptoms of vascular access problems, Doppler flow studies may be used as a means to obtain diagnostic information to permit medical intervention to address the problem. Doppler flow studies may be considered medically necessary in the presence of signs or symptoms of possible failure of the ESRD patient s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient. Medicare pays for the technical component of the procedure in the composite payment rate. Where there are signs and symptoms of vascular access problems, Doppler flow studies may be used as a means to obtain diagnostic information to permit medical intervention to address the problem. Doppler flow studies may be considered medically necessary in the presence of signs or symptoms of possible failure of the ESRD patient s vascular access site, and when the results are used in determining the clinical course of the treatment for the patient.

The only Current Procedural Terminology (CPT) billing code for non-invasive vascular testing of a hemodialysis access site is 93990. Billing for monitoring of hemodialysis access using CPT codes for non-invasive vascular studies other than 93990 is considered a misrepresentation of the service actually provided. Medicare will deny separate payment of the technical component of this code if it is performed on any patient for whom the ESRD composite rate for dialysis is being paid, unless there is appropriate medical indication of the need for a Doppler flow study. Coding Guidelines 1. Use the appropriate procedure code and modifiers. 2. Indicate the diagnoses for which the testing is being performed. 3. Documentation is not required on initial claims submission unless requested. 4. If studies are performed on the upper and lower extremities on the same day, the services should be submitted on separate detail lines. When claims are submitted electronically, it should be indicated in Item19 of field N-4 (old format) or in record HAO-05 of the National Standard format, that upper AND lower studies were performed. If paper claims are still being submitted, this information must appear on the CMS-1500 claim form. The submitted medical record should support the use of the selected diagnostic codes and the CPT/HCPCS codes should accurately describe the studies performed. If modifiers are reported, the documentation must support the use of these modifiers. Note: A payable diagnosis alone does not support medical necessity of ANY service. The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Revision history