CMS Limitations Guide - Radiology Services - Munson Home Care

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

(L35751) Non-Invasive Peripheral Venous Vascular and Hemodialysis

Access Studies

USV CALF REFLUX STUDY BILATERAL (93965) USV DIALYSIS GRAFT (93990) USV HEMODIALYSIS (93990) USV LOWER EXTREMITY VEIN BILATERAL (93970) USV LOWER EXTREMITY VEIN RIGHT OR LEFT (93971) USV UPPER EXTREMITY VEIN BILATERAL (93970) USV UPPER EXTREMITY VEIN RIGHT OR LEFT (93971)

CPT Code 93965

93970

Description

Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler Waveform analysis with responses to compression and other maneuvers, Phleborheography, Impedance Plethysmography) (USV Calf Reflux Study Bilateral)

Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (USV Lower Ext Vein Bilat) (USV Upper Ext Vein Bilat)

93971

Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (USV Lower Ext Vein RT or LT) (USV Upper Ext Vein RT or LT)

93990

Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) (USV Dialysis Graft) (USV Hemodialysis)

G0365

Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow)

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

Group 1 Paragraph: Peripheral Venous Examinations (93965, 93970, and 93971)

Group 1 Codes:

Code

Description

D68.51

Activated protein C resistance

D68.52

Prothrombin gene mutation

D68.59

Other primary thrombophilia

D68.61

Antiphospholipid syndrome

D68.62

Lupus anticoagulant syndrome

D68.69

Other thrombophilia

D75.81

Myelofibrosis

D75.82

Heparin induced thrombocytopenia (HIT)

D75.89

Other specified diseases of blood and blood-forming organs

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

CMS Limitations Guide ? Radiology Services

I26.92 I26.99 I27.82 I80.01 I80.02 I80.03 I80.11 I80.12 I80.13 I80.211 I80.212 I80.213 I80.221 I80.222 I80.223 I80.231 I80.232 I80.233 I80.291 I80.292 I80.293 I80.8 I82.1 I82.210 I82.211 I82.290 I82.291 I82.411 I82.412 I82.413 I82.421 I82.422 I82.423 I82.431 I82.432 I82.433 I82.441

Saddle embolus of pulmonary artery without acute cor pulmonale Other pulmonary embolism without acute cor pulmonale Chronic pulmonary embolism Phlebitis and thrombophlebitis of superficial vessels of right lower extremity Phlebitis and thrombophlebitis of superficial vessels of left lower extremity Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral Phlebitis and thrombophlebitis of right femoral vein Phlebitis and thrombophlebitis of left femoral vein Phlebitis and thrombophlebitis of femoral vein, bilateral Phlebitis and thrombophlebitis of right iliac vein Phlebitis and thrombophlebitis of left iliac vein Phlebitis and thrombophlebitis of iliac vein, bilateral Phlebitis and thrombophlebitis of right popliteal vein Phlebitis and thrombophlebitis of left popliteal vein Phlebitis and thrombophlebitis of popliteal vein, bilateral Phlebitis and thrombophlebitis of right tibial vein Phlebitis and thrombophlebitis of left tibial vein Phlebitis and thrombophlebitis of tibial vein, bilateral Phlebitis and thrombophlebitis of other deep vessels of right lower extremity Phlebitis and thrombophlebitis of other deep vessels of left lower extremity Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral Phlebitis and thrombophlebitis of other sites 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 Acute embolism and thrombosis of right femoral vein Acute embolism and thrombosis of left femoral vein Acute embolism and thrombosis of femoral vein, bilateral Acute embolism and thrombosis of right iliac vein Acute embolism and thrombosis of left iliac vein Acute embolism and thrombosis of iliac vein, bilateral Acute embolism and thrombosis of right popliteal vein Acute embolism and thrombosis of left popliteal vein Acute embolism and thrombosis of popliteal vein, bilateral Acute embolism and thrombosis of right tibial vein

CMS Limitations Guide ? Radiology Services

I82.442 I82.443 I82.491 I82.492 I82.493 I82.511 I82.512 I82.513 I82.521 I82.522 I82.523 I82.531 I82.532 I82.533 I82.541 I82.542 I82.543 I82.591 I82.592 I82.593 I82.611 I82.612 I82.613 I82.621 I82.622 I82.623 I82.711 I82.712 I82.713 I82.721 I82.722 I82.723 I82.A11 I82.A12 I82.A13 I82.A21 I82.A22

Acute embolism and thrombosis of left tibial vein Acute embolism and thrombosis of tibial vein, bilateral Acute embolism and thrombosis of other specified deep vein of right lower extremity Acute embolism and thrombosis of other specified deep vein of left lower extremity Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral Chronic embolism and thrombosis of right femoral vein Chronic embolism and thrombosis of left femoral vein Chronic embolism and thrombosis of femoral vein, bilateral Chronic embolism and thrombosis of right iliac vein Chronic embolism and thrombosis of left iliac vein Chronic embolism and thrombosis of iliac vein, bilateral Chronic embolism and thrombosis of right popliteal vein Chronic embolism and thrombosis of left popliteal vein Chronic embolism and thrombosis of popliteal vein, bilateral Chronic embolism and thrombosis of right tibial vein Chronic embolism and thrombosis of left tibial vein Chronic embolism and thrombosis of tibial vein, bilateral Chronic embolism and thrombosis of other specified deep vein of right lower extremity Chronic embolism and thrombosis of other specified deep vein of left lower extremity Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral Acute embolism and thrombosis of superficial veins of right upper extremity Acute embolism and thrombosis of superficial veins of left upper extremity Acute embolism and thrombosis of superficial veins of upper extremity, bilateral Acute embolism and thrombosis of deep veins of right upper extremity Acute embolism and thrombosis of deep veins of left upper extremity Acute embolism and thrombosis of deep veins of upper extremity, bilateral Chronic embolism and thrombosis of superficial veins of right upper extremity Chronic embolism and thrombosis of superficial veins of left upper extremity Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral Chronic embolism and thrombosis of deep veins of right upper extremity Chronic embolism and thrombosis of deep veins of left upper extremity Chronic embolism and thrombosis of deep veins of upper extremity, bilateral Acute embolism and thrombosis of right axillary vein Acute embolism and thrombosis of left axillary vein Acute embolism and thrombosis of axillary vein, bilateral Chronic embolism and thrombosis of right axillary vein Chronic embolism and thrombosis of left axillary vein

CMS Limitations Guide ? Radiology Services

I82.A23 I82.B11 I82.B12 I82.B13 I82.B21 I82.B22 I82.B23 I82.C11 I82.C12 I82.C13 I82.C21 I82.C22 I82.C23 I82.811 I82.812 I82.813 I82.890 I82.891 I83.011 I83.012 I83.013 I83.014 I83.015 I83.018 I83.021 I83.022 I83.023 I83.024 I83.025 I83.028 I83.11 I83.12 I83.211 I83.212 I83.213 I83.214 I83.215

Chronic embolism and thrombosis of axillary vein, bilateral Acute embolism and thrombosis of right subclavian vein Acute embolism and thrombosis of left subclavian vein Acute embolism and thrombosis of subclavian vein, bilateral Chronic embolism and thrombosis of right subclavian vein Chronic embolism and thrombosis of left subclavian vein Chronic embolism and thrombosis of subclavian vein, bilateral Acute embolism and thrombosis of right internal jugular vein Acute embolism and thrombosis of left internal jugular vein Acute embolism and thrombosis of internal jugular vein, bilateral Chronic embolism and thrombosis of right internal jugular vein Chronic embolism and thrombosis of left internal jugular vein Chronic embolism and thrombosis of internal jugular vein, bilateral Embolism and thrombosis of superficial veins of right lower extremities Embolism and thrombosis of superficial veins of left lower extremities Embolism and thrombosis of superficial veins of lower extremities, bilateral Acute embolism and thrombosis of other specified veins Chronic embolism and thrombosis of other specified veins Varicose veins of right lower extremity with ulcer of thigh Varicose veins of right lower extremity with ulcer of calf Varicose veins of right lower extremity with ulcer of ankle Varicose veins of right lower extremity with ulcer of heel and midfoot Varicose veins of right lower extremity with ulcer other part of foot Varicose veins of right lower extremity with ulcer other part of lower leg Varicose veins of left lower extremity with ulcer of thigh Varicose veins of left lower extremity with ulcer of calf Varicose veins of left lower extremity with ulcer of ankle Varicose veins of left lower extremity with ulcer of heel and midfoot Varicose veins of left lower extremity with ulcer other part of foot Varicose veins of left lower extremity with ulcer other part of lower leg Varicose veins of right lower extremity with inflammation Varicose veins of left lower extremity with inflammation Varicose veins of right lower extremity with both ulcer of thigh and inflammation Varicose veins of right lower extremity with both ulcer of calf and inflammation Varicose veins of right lower extremity with both ulcer of ankle and inflammation Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation Varicose veins of right lower extremity with both ulcer other part of foot and inflammation

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