CMS Limitations Guide - Radiology Services

[Pages:15]CMS Limitations Guide - Radiology Services

Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes.

This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: .

CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient's test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses.

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: medicalnecessity.

If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 9357493.

CMS Limitations Guide ? Radiology Services

(L35755) Non-Invasive Abdominal/Visceral Vascular Studies

USV Liver Doppler (93975) USV Mesenteric Doppler (93975) USV Renal Artery (93975)

CPT Code 93975

93976 93978 93979 93980 93981

Description

Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; Complete study (USV Liver Doppler) (USV Mesenteric Doppler) (USV Renal Artery) Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; Limited study Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; Complete study

Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; Unilateral or limited study Duplex scan of arterial inflow and venous outflow of penile vessels; Complete study

Duplex scan of arterial inflow and venous outflow of penile vessels; Follow-up or Limited study

ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program:

Group 1 Paragraph: Abdominal/visceral vascular studies of abdominal, retroperitoneal, and pelvic organs (93975 and 93976)

Use diagnosis code R09.89 (other specified symptoms and signs involving the circulatory and respiratory systems) to report abdominal bruit.

For codes in the table below that requires a 7th character: letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 1 Codes:

Code

Description

I10

Essential (primary) hypertension

I11.0

Hypertensive heart disease with heart failure

I11.9

Hypertensive heart disease without heart failure

I12.0 I12.9 I13.0 I13.10 I13.11 I13.2 I15.0

Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease Renovascular hypertension

I15.1

Hypertension secondary to other renal disorders

I15.2

Hypertension secondary to endocrine disorders

I15.8

Other secondary hypertension

CMS Limitations Guide ? Radiology Services

I70.1 I71.1 I71.2 I71.3 I71.4 I71.5 I71.6 I72.2 I74.5 I75.81 I76 I77.2 I77.3 I77.4 I77.73 I81 I82.0 I82.1 I82.210 I82.211 I82.290 I82.291 I82.3 I86.1 I86.2 I86.3 I86.4 I86.8 K55.0 K55.1 K55.8 K70.2 K70.30 K70.31 K74.0 K74.60 K74.69

Atherosclerosis of renal artery Thoracic aortic aneurysm, ruptured Thoracic aortic aneurysm, without rupture Abdominal aortic aneurysm, ruptured Abdominal aortic aneurysm, without rupture Thoracoabdominal aortic aneurysm, ruptured Thoracoabdominal aortic aneurysm, without rupture Aneurysm of renal artery Embolism and thrombosis of iliac artery Atheroembolism of kidney Septic arterial embolism Rupture of artery Arterial fibromuscular dysplasia Celiac artery compression syndrome Dissection of renal artery Portal vein thrombosis Budd-Chiari syndrome Thrombophlebitis migrans Acute embolism and thrombosis of superior vena cava Chronic embolism and thrombosis of superior vena cava Acute embolism and thrombosis of other thoracic veins Chronic embolism and thrombosis of other thoracic veins Embolism and thrombosis of renal vein Scrotal varices Pelvic varices Vulval varices Gastric varices Varicose veins of other specified sites Acute vascular disorders of intestine Chronic vascular disorders of intestine Other vascular disorders of intestine Alcoholic fibrosis and sclerosis of liver Alcoholic cirrhosis of liver without ascites Alcoholic cirrhosis of liver with ascites Hepatic fibrosis Unspecified cirrhosis of liver Other cirrhosis of liver

CMS Limitations Guide ? Radiology Services

K76.6 N17.0 N17.1 N17.2 N17.8 N17.9 N18.1 N18.2 N18.3 N18.4 N18.5 N26.1 N26.2 N26.9 N27.0 N27.1 N28.0 N29 N43.0 N43.1 N43.2 N43.3 N43.40 N43.41 N43.42 N44.00 N44.01 N44.02 N44.03 N44.04 N44.1 N44.2 N44.8 N45.1 N45.2 N45.3 N45.4

Portal hypertension Acute kidney failure with tubular necrosis Acute kidney failure with acute cortical necrosis Acute kidney failure with medullary necrosis Other acute kidney failure Acute kidney failure, unspecified Chronic kidney disease, stage 1 Chronic kidney disease, stage 2 (mild) Chronic kidney disease, stage 3 (moderate) Chronic kidney disease, stage 4 (severe) Chronic kidney disease, stage 5 Atrophy of kidney (terminal) Page kidney Renal sclerosis, unspecified Small kidney, unilateral Small kidney, bilateral Ischemia and infarction of kidney Other disorders of kidney and ureter in diseases classified elsewhere Encysted hydrocele Infected hydrocele Other hydrocele Hydrocele, unspecified Spermatocele of epididymis, unspecified Spermatocele of epididymis, single Spermatocele of epididymis, multiple Torsion of testis, unspecified Extravaginal torsion of spermatic cord Intravaginal torsion of spermatic cord Torsion of appendix testis Torsion of appendix epididymis Cyst of tunica albuginea testis Benign cyst of testis Other noninflammatory disorders of the testis Epididymitis Orchitis Epididymo-orchitis Abscess of epididymis or testis

CMS Limitations Guide ? Radiology Services

N49.1 N49.2 N49.3 N49.8 N49.9 N50.0 N50.1 N50.3 N50.8 N50.9 N51 N53.12 N53.8 N53.9 N83.51 N83.52 N83.53 Q26.5 Q26.6 Q27.1 Q27.2 Q27.33 Q27.34 Q60.0 Q60.1 Q60.3 Q60.4 Q60.6 Q61.01 Q61.02 Q61.11 Q61.19 Q61.2 Q61.4 Q61.5 Q61.8 R09.89

Inflammatory disorders of spermatic cord, tunica vaginalis and vas deferens Inflammatory disorders of scrotum Fournier gangrene Inflammatory disorders of other specified male genital organs Inflammatory disorder of unspecified male genital organ Atrophy of testis Vascular disorders of male genital organs Cyst of epididymis Other specified disorders of male genital organs Disorder of male genital organs, unspecified Disorders of male genital organs in diseases classified elsewhere Painful ejaculation Other male sexual dysfunction Unspecified male sexual dysfunction Torsion of ovary and ovarian pedicle Torsion of fallopian tube Torsion of ovary, ovarian pedicle and fallopian tube Anomalous portal venous connection Portal vein-hepatic artery fistula Congenital renal artery stenosis Other congenital malformations of renal artery Arteriovenous malformation of digestive system vessel Arteriovenous malformation of renal vessel Renal agenesis, unilateral Renal agenesis, bilateral Renal hypoplasia, unilateral Renal hypoplasia, bilateral Potter's syndrome Congenital single renal cyst Congenital multiple renal cysts Cystic dilatation of collecting ducts Other polycystic kidney, infantile type Polycystic kidney, adult type Renal dysplasia Medullary cystic kidney Other cystic kidney diseases Other specified symptoms and signs involving the circulatory and respiratory systems

CMS Limitations Guide ? Radiology Services

R10.0 R10.11 R10.12 R10.13 R10.2 R10.31 R10.32 R10.33 R10.84 R18.0 R18.8 R19.00 R19.01 R19.02 R19.03 R19.04 R19.05 R19.06 R19.07 R19.09 R19.31 R19.32 R19.33 R19.34 R19.35 R19.36 R19.37 R94.4 S35.11XA S35.12XA S35.19XA S35.211A S35.212A S35.218A S35.221A S35.222A S35.228A

Acute abdomen Right upper quadrant pain Left upper quadrant pain Epigastric pain Pelvic and perineal pain Right lower quadrant pain Left lower quadrant pain Periumbilical pain Generalized abdominal pain Malignant ascites Other ascites Intra-abdominal and pelvic swelling, mass and lump, unspecified site Right upper quadrant abdominal swelling, mass and lump Left upper quadrant abdominal swelling, mass and lump Right lower quadrant abdominal swelling, mass and lump Left lower quadrant abdominal swelling, mass and lump Periumbilic swelling, mass or lump Epigastric swelling, mass or lump Generalized intra-abdominal and pelvic swelling, mass and lump Other intra-abdominal and pelvic swelling, mass and lump Right upper quadrant abdominal rigidity Left upper quadrant abdominal rigidity Right lower quadrant abdominal rigidity Left lower quadrant abdominal rigidity Periumbilic abdominal rigidity Epigastric abdominal rigidity Generalized abdominal rigidity Abnormal results of kidney function studies Minor laceration of inferior vena cava, initial encounter Major laceration of inferior vena cava, initial encounter Other injury of inferior vena cava, initial encounter Minor laceration of celiac artery, initial encounter Major laceration of celiac artery, initial encounter Other injury of celiac artery, initial encounter Minor laceration of superior mesenteric artery, initial encounter Major laceration of superior mesenteric artery, initial encounter Other injury of superior mesenteric artery, initial encounter

CMS Limitations Guide ? Radiology Services

S35.291A S35.292A S35.298A S35.311A S35.318A S35.321A S35.328A S35.331A S35.338A S35.341A S35.348A S35.411A S35.412A S35.413A S35.414A S35.415A S35.416A S35.491A S35.492A S35.493A S35.494A S35.495A S35.496A S35.511A S35.512A S35.514A S35.515A S35.531A S35.532A S35.534A S35.535A S35.8X1A S35.8X8A

T81.710A

T81.710D

T81.710S

Minor laceration of branches of celiac and mesenteric artery, initial encounter Major laceration of branches of celiac and mesenteric artery, initial encounter Other injury of branches of celiac and mesenteric artery, initial encounter Laceration of portal vein, initial encounter Other specified injury of portal vein, initial encounter Laceration of splenic vein, initial encounter Other specified injury of splenic vein, initial encounter Laceration of superior mesenteric vein, initial encounter Other specified injury of superior mesenteric vein, initial encounter Laceration of inferior mesenteric vein, initial encounter Other specified injury of inferior mesenteric vein, initial encounter Laceration of right renal artery, initial encounter Laceration of left renal artery, initial encounter Laceration of unspecified renal artery, initial encounter Laceration of right renal vein, initial encounter Laceration of left renal vein, initial encounter Laceration of unspecified renal vein, initial encounter Other specified injury of right renal artery, initial encounter Other specified injury of left renal artery, initial encounter Other specified injury of unspecified renal artery, initial encounter Other specified injury of right renal vein, initial encounter Other specified injury of left renal vein, initial encounter Other specified injury of unspecified renal vein, initial encounter Injury of right iliac artery, initial encounter Injury of left iliac artery, initial encounter Injury of right iliac vein, initial encounter Injury of left iliac vein, initial encounter Injury of right uterine artery, initial encounter Injury of left uterine artery, initial encounter Injury of right uterine vein, initial encounter Injury of left uterine vein, initial encounter Laceration of other blood vessels at abdomen, lower back and pelvis level, initial encounter Other specified injury of other blood vessels at abdomen, lower back and pelvis level, initial encounter Complication of mesenteric artery following a procedure, not elsewhere classified, initial encounter Complication of mesenteric artery following a procedure, not elsewhere classified, subsequent encounter Complication of mesenteric artery following a procedure, not elsewhere classified, sequela

CMS Limitations Guide ? Radiology Services

T81.711A T81.711D

T81.711S T82.817A T82.827A T82.837A T82.847A T82.857A T82.867A T82.897A T86.11 T86.12 T86.13 T86.19 T86.41 T86.42 T86.43 T86.49 T86.850 T86.851 T86.852 T86.858 Z48.03 Z48.812 Z48.89

Complication of renal artery following a procedure, not elsewhere classified, initial encounter Complication of renal artery following a procedure, not elsewhere classified, subsequent encounter Complication of renal artery following a procedure, not elsewhere classified, sequela Embolism of cardiac prosthetic devices, implants and grafts, initial encounter Fibrosis of cardiac prosthetic devices, implants and grafts, initial encounter Hemorrhage of cardiac prosthetic devices, implants and grafts, initial encounter Pain from cardiac prosthetic devices, implants and grafts, initial encounter Stenosis of cardiac prosthetic devices, implants and grafts, initial encounter Thrombosis of cardiac prosthetic devices, implants and grafts, initial encounter Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter Kidney transplant rejection Kidney transplant failure Kidney transplant infection Other complication of kidney transplant Liver transplant rejection Liver transplant failure Liver transplant infection Other complications of liver transplant Intestine transplant rejection Intestine transplant failure Intestine transplant infection Other complications of intestine transplant Encounter for change or removal of drains Encounter for surgical aftercare following surgery on the circulatory system Encounter for other specified surgical aftercare

Group 2 Paragraph: Visceral vascular studies of aorta, inferior vena cava, iliac vasculature, and bypass grafts (93978 and 93979)

For codes in the table below that require a 7th character: letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 2 Codes:

Code

Description

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

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