Billing and Coding: Non-Invasive Cerebrovascular Studies

The billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the related LCD. 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 for coverage as described in the Coverage Indications, Limitations, and/or Medical Necessity section of this LCD. There should be a permanent record of the studies performed and the interpretation. The documentation should include a description of the studies performed and any contrast media and/or radiopharmaceuticals used. Any known significant patient reaction or complications should be recorded. Comparison with prior relevant studies needs to be addressed in the documentation along with both normal and abnormal findings. Variations from normal should be documented along with the measurements. The report should address or answer any specific clinical questions. If there are factors that prevent answering the clinical questions, this should be explained in the documentation. Retention of the ultrasound examination images should be consistent both with clinical need and with relevant legal and local health care facility requirements. If the provider of the study is other than the ordering/referring physician/nonphysician practitioner, that provider must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician 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. Documentation must be provided supporting the need for more than 1 imaging study or a repeat preoperative scan. 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. Only 1 Doppler preoperative scan is considered reasonable and necessary for bypass surgery. If a more current preoperative scan is indicated for a patient with multiple comorbidities having difficulty being stabilized for surgery or a change in condition, the medical record would need to support the medical necessity of the second scan. Re-evaluation of existing carotid stenosis. Patients demonstrating a diameter reduction of greater than 50% with symptoms and those patients with > 60% with no symptoms are normally followed on an annual basis. If patients become symptomatic of carotid disease repeat duplex scans are allowed without regard to the above schedule. Follow-up after a carotid endarterectomy (outside the global period). These patients are normally followed with duplex ultrasonography on the affected side at 6 weeks, 6 months, and annually thereafter unless symptoms develop. During the first year, follow-up studies should be on the ipsilateral side unless signs and symptoms or previously identified disease in the contralateral carotid artery provide indications for a bilateral procedure. Multiple cerebrovascular procedures may be allowed during the same encounter given the physician/non-physician can demonstrate medical necessity as documented in the patient’s medical record. Preventive and/or screening services unless covered in Statute are not covered by Medicare.