Billing and Coding: Non-Invasive Peripheral Venous Vascular and Hemodialysis Access 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 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 non-invasive vascular studies would not be performed more than once in a year, excluding inpatient hospital (21) and emergency room (23) places of services. Only 1 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 1 limited study is considered reasonable and necessary post operatively within 72 hours of a saphenous vein ablation, whether surgery is performed on one side or bilaterally. Pre-surgical conduit mapping of the radial artery(ies) should only be accompanied by vein-mapping studies when the arterial studies demonstrate a non-acceptable conduit, or an insufficient conduit is available for multiple bypass procedures. Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease. The documentation must support medical necessity. Documentation must be provided supporting the need for more than 1 imaging study Doppler flow or vessel mapping and arteriogram. Performance of both non-invasive extracranial arterial studies and non-invasive evaluation of extremity veins during the same encounter is not appropriate as a general practice or standing protocol, and therefore, generally would not be expected to be done together. Consequently, documentation must clearly support the medical necessity if both procedures are performed during the same encounter. Preventive and/or screening services unless covered in Statute are not covered by Medicare.