Appropriate Billing of Duplex Scans
Issue: #395 JUL2017
Several questions have been raised regarding appropriate billing of duplex scans of visceral organs and abdominal ultrasounds, billed under Current Procedural Terminology (CPT®) codes 93975-93976.
- 93975 – Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study
- 93976 – Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; limited study
CPT® code 93975 describes evaluation of arterial inflow and venous outflow of abdomen, retroperitoneum, scrotal contents and/or pelvic organs. This code can be used whether single or multiple organs are studied. It is a “complete” procedure in that all major vessels supplying blood flow to the organs are evaluated. If the study is only a partial evaluation, then the limited code (93976) is billed.
Noninvasive vascular diagnostic duplex scans should only be used when medically necessary, appropriately documented, and when both spectral and color Doppler are performed. To meet medical necessity, there must be a high index of suspicion that the pain is caused by a vascular disorder. A duplex scan should not be coded when color is just turned on to determine if a structure is vascular or to determine the presence of flow. Color Doppler alone, when performed for anatomic structure identification in conjunction with a real-time ultrasound examination, is not reported separately. Spectral Doppler, which includes a mention of the wave forms or resistive index (RI), is required to demonstrate performance of that portion of the test. For example, a patient comes in with pelvic pain, and the ultrasound of the pelvis demonstrates an enlarged ovary. The differential diagnosis includes torsion of the ovary. If color Doppler is used only to determine flow and viability of the ovary, the duplex scan is not separately reportable. If the spectral analysis is performed to report on the waveforms or RI, then it would be appropriate to code 76856-59 for the pelvic ultrasound and 93976 for the limited vascular study of the ovary. The ordering practitioner’s documentation should support how these results are being used in the member’s care.
Documentation requirements include a valid order, images integrating B-mode two-dimensional vascular structure, an assessment of flow with color and imaging, Doppler spectral waveform analysis, and a report of the findings should all be present to assign a duplex CPT® code. If appropriate documentation is not in the report, only a non-vascular ultrasound code should be submitted.
The practitioner who is treating the member must order all diagnostic X-ray tests, diagnostic laboratory tests and other diagnostic tests. The practitioner who treats the member is the practioner who furnishes a consultation, treats a member for a specific medical problem, and uses the results in the management of the member’s specific medical problem. Tests not ordered by the practitioner are not reasonable and necessary.
Documentation of an “order” is a communication from the treating practitioner requesting that a diagnostic test be performed for a patient. The order may conditionally request an additional diagnostic test for a particular patient if the result of the initial diagnostic test ordered yields to a certain value determined by the treating practitioner. When an interpreting physician at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed, the interpreting physician/testing facility may not perform the unordered test until a new order from the treating practitioner has been received. If the testing facility cannot reach the treating practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all the following criteria apply:
- The testing center performs the diagnostic test ordered by the treating practitioner;
- The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary;
- Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the member;
- The result of the test is communicated to and is used by the treating practitioner in the treatment of the member; and
- The interpreting physician at the testing facility documents in his/her report why additional testing was done.