VASCULARULTRASOUND

For example, if the technologist quickly turns on the color Doppler to evaluate for flow in the scrotal arteries during a testicular ultrasound, only the testicular UScode (76870) should be reported According to CPT® Assistant, March 2015, a duplex scan may be reported in addition to a non-vascular diagnostic ultrasound of the same anatomic site (e g , 93975 with 76700) when both services are performed and documented appropriately.

Duplex scanning should not be regularly performed on every patient who receives a diagnostic ultrasound study According to Clinical Examplesin Radiology(Winter 2013), if there is no order from the referring physician for a duplex scan, there must be ?a detailed explanation by the radiologist in [their] report as to why the Doppler was medically necessary.?

Docum ent at ion

The radiologist should detail the exam protocol in their documentation to facilitate correct billing and prevent complications in the event of an audit. As indicated in Clinical Examplesin Radiology(Spring 2012):

?At the very minimum, the technique part of the report should state that ?AduplexDoppler studywasperformed.?Ideally, it should state, for example, ?AduplexDoppler studywas performed, consistingof integrated two-dimensional (2D) real-timeimaging, color flowDoppler, and Doppler spectral analysisutilizing5.0 MHz and 7.0MHz linear arrayprobes.?The body of the report should optimally describe that normal flow, compressibility, and augmentation were demonstrated on Doppler spectral analysis.?

If the radiologist explicitly says that a duplex study was done, the performance of a B-mode 2D US, color Doppler, and spectral Doppler is inferred. If the physician does not indicate performance of a duplex study, both color flow and spectral Doppler must be clearly documented in the report

Clinical Examplesin Radiology(Spring 2012) indicates that documentation of color Doppler without mention of spectral Doppler does not adequately support the assignment of a duplex code Additionally, Clinical Examplesin Radiology(Spring 2007 and Spring 2008) contain detailed examples of how to appropriately document interpretation of these studies within the radiology report.

Vascularultrasound

The American College of Radiology Ultrasound CodingUser?sGuide identifies examples of terminology that would support performance of a Doppler examination:

- Analog velocity

- Bandwidth broadening

- Monophasic

- Peak systolic velocity

- Phasicity

- Power Doppler

- Pulsed Doppler

- Pulsatility

- Resistive index

- Spectral analysis

- Spectral broadening

- Spectral Doppler

- Tardus parvus waveforms

- Triphasic

- Velocity

- Duplex Doppler

Vascular ultrasound, as with other diagnostic USstudies, requires that permanent images be obtained and archived in the medical record or PACS. It is not required that the report document that permanent images were acquired. However, it is recommended that the provider or facility document this information

The technique must support the performance of a duplex exam, but the report must also identify the presence, absence, or other characteristics of blood flow in the vessels being assessed Per Clinical Examplesin Radiology(Spring 2020), specific information pertaining to the flow parameters, waveforms, velocities, or resistive indices may be recorded when the interpreting physician deems them significant.

Coding Guidance

There are specific CPT® codes for non-invasive vascular ultrasound of certain anatomic areas. These include the cerebrovascular arteries (93875-93888), extremity arteries (93922- 93931), extremity veins (93965-93971), visceral arterial inflow and venous outflow (93975- 93981), and hemodialysis access scanning (93990)

If a limited bilateral non-invasive vascular ultrasound study of the extremities is performed, choose the appropriate code from the ?unilateral or limited study?codes (93926, 93931, 93971) These codes correspond to unilateral (or limited unilateral) studies, but also to limited bilateral studies When both the upper and lower extremities are evaluated, two units of the

Vascularultrasound

If a limited bilateral non-invasive vascular ultrasound study of the extremities is performed, choose the appropriate code from the ?unilateral or limited study?codes (93926, 93931, 93971) These codes correspond to unilateral (or limited unilateral) studies, but also to limited bilateral studies When both the upper and lower extremities are evaluated, two units of the appropriate code should be reported

If both non-vascular diagnostic ultrasound and duplex are performed, both must be medically necessary and meet CPT® documentation requirements for the technique and structures identified. It is recommended that the radiologist dictate separate reports for the two studies, or at least describe the two studies under separate headings / paragraphs within the same report If a combined report is issued, the content of the documentation for each USshould align with the typical documentation for when they are performed as stand-alone exams.

Under National Correct Coding Initiative (NCCI) edits, certain non-vascular diagnostic ultrasound codes are bundled into the duplex study code for the same anatomic area. Append modifier -59 or -XU to the non-vascular ultrasound code when a complete, separate, medically necessary study is performed and documented The National Correct Coding Policy Manual, Chapter 9 states:

?Abdominal ultrasound examinations (CPT® codes 76700-76775) and abdominal duplex examinations (CPT® codes 93975, 93976) are generally performed for different clinical scenarios, although there are some instances where both types of procedures are medically reasonable and necessary. In the latter case, the abdominal ultrasound procedure CPT® code should be reported with an NCCI PTP-associated modifier.?

Clinical Examplesin Radiology(Summer 2012) dictates that while a duplex study falls under the "test design" exception to Medicare?s regulations for ordering diagnostic tests (and thus does not require a physician order), it is essential to review individual payer policies, as not all will align with this explanation

Vascularultrasound

Non-Invasive Physiologic St udies

Non-invasive physiologic studies (NIPS) are functional measurement studies that examine and confirm vascular insufficiency and occlusive disease without imaging These studies include ankle-brachial index (ABI), Doppler analysis, plethysmography, and oxygen tension measurements. The ABI evaluates circulation in the extremities using a blood pressure cuff and a handheld Doppler unit. Blood pressure measurements are taken at various arterial sites, and the ABI is calculated based on the systolic pressure readings ABIs performed alone without any other physiologic studies are not separately reportable, as CPT® includes them in the provider's evaluation and management service.

Coverage

Many Medicare contractors have released Local Coverage Determinations (LCDs) and/or Supplemental Instruction Articles for vascular ultrasound, which include instructions on coverage and billing for each MAC. Prior to billing for these services, it is essential to review local policy

Most insurance providers do not allow reimbursement for both a duplex scan and a noninvasive physiologic study on the same anatomic area. Some payers have expressly indicated that physiologic testing will not be covered if a duplex study has already been conducted

For example, Cigna?s policy appears on the next page:

Having a clear understanding of the technology and terminology associated with duplex and Doppler exams is vital for ensuring appropriate documentation, charging, and billing for these services

Addit ional Resources

For additional information, please see the following PARA Papers, also available in the Advisor tab of the PARA Data Editor.

Q&A: Upper and Lower Extremity Venous Duplex

Q&A: Duplex Ultrasound

Q&A: Duplex Scan

Ultrasound Documentation Requirements: Complete vs Limited

Ultrasound Guidance in the Hospital Setting