Billing and Coding: Endovenous Stenting

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L38231, Endovenous Stenting. Please refer to the LCD for reasonable and necessary requirements. Medicare reimbursement for endovenous stenting is limited to the treatment of severely symptomatic venous obstructions as outlined in the related LCD. Coding Guidance Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Claims must be submitted with an ICD-10-CM code that represents the reason the procedure was done. The ICD-10-CM code must be billed to the highest level of specificity for that code set. The ICD-10-CM code must be linked to the appropriate procedure code. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Medical record documentation should list type and length of conservative treatment as applicable per the LCD. Pre- and post-deployment intervention images should be obtained and made available upon request. Intermediate stages pertinent to the endovascular procedure may also be documented with images. Details should include the position of the device, and when appropriate, the nature of the obstruction (if a determination can be made regarding the etiology), and effect of the device on target or nontarget vessels. Medical record documentation should list guide catheter used, as well as stent type, diameter and length.