CMS Limitations Guide - Radiology Services

[Pages:14]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

(L35753) Non-Invasive Cerebrovascular Studies

USV Carotid (93880)

Group 1 Paragraph: Note: Diagnosis codes must be coded to the highest level of specificity.

CPT Code Description

93880

Duplex scan of extracranial arteries; complete bilateral study (USV Carotid)

93882

Duplex scan of extracranial arteries; unilateral or limited study

93886

Transcranial Doppler study of the intracranial arteries; complete study

93888

Transcranial Doppler study of the intracranial arteries; limited study

93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892 93893

Transcranial Doppler study of the intracranial arteries; Emboli detection without intravenous microbubble injection Transcranial Doppler study of the intracranial arteries; Emboli detection with intravenous microbubble injection

Group 2 Paragraph: NON-COVERED

Group 2 Codes:

CPT Code Description

93895

Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral

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

Group 1 Paragraph: Extracranial Arteries Studies (93880-93882) Use a diagnosis code of R22.1 (localized swelling, mass, and lump, neck) to report pulsatile neck mass. Use a diagnosis code of H93.11, H93.12, or H93.13 to report pulsatile tinnitus. Use a diagnosis code of R09.89 (Other specified symptoms and signs involving the circulatory and respiratory systems) to report a carotid bruit.

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 1 Codes:

Code

Description

G04.1

Tropical spastic paraplegia

G45.0

Vertebro-basilar artery syndrome

G45.1

Carotid artery syndrome (hemispheric)

G45.2

Multiple and bilateral precerebral artery syndromes

G45.3

Amaurosis fugax

G45.4

Transient global amnesia

G45.8

Other transient cerebral ischemic attacks and related syndromes

G46.0

Middle cerebral artery syndrome

G46.1

Anterior cerebral artery syndrome

G46.2

Posterior cerebral artery syndrome

G81.01

Flaccid hemiplegia affecting right dominant side

G81.02

Flaccid hemiplegia affecting left dominant side

CMS Limitations Guide ? Radiology Services

G81.03 G81.04 G81.11 G81.12 G81.13 G81.14 G81.91 G81.92 G81.93 G81.94 G82.21 G82.22 G82.51 G82.52 G82.53 G82.54 G83.0 G83.11 G83.12 G83.13 G83.14 G83.21 G83.22 G83.23 G83.24 G83.31 G83.32 G83.33 G83.34 G83.9 G93.82 G97.31

G97.32

G97.48

G97.49

Flaccid hemiplegia affecting right nondominant side Flaccid hemiplegia affecting left nondominant side Spastic hemiplegia affecting right dominant side Spastic hemiplegia affecting left dominant side Spastic hemiplegia affecting right nondominant side Spastic hemiplegia affecting left nondominant side Hemiplegia, unspecified affecting right dominant side Hemiplegia, unspecified affecting left dominant side Hemiplegia, unspecified affecting right nondominant side Hemiplegia, unspecified affecting left nondominant side Paraplegia, complete Paraplegia, incomplete Quadriplegia, C1-C4 complete Quadriplegia, C1-C4 incomplete Quadriplegia, C5-C7 complete Quadriplegia, C5-C7 incomplete Diplegia of upper limbs Monoplegia of lower limb affecting right dominant side Monoplegia of lower limb affecting left dominant side Monoplegia of lower limb affecting right nondominant side Monoplegia of lower limb affecting left nondominant side Monoplegia of upper limb affecting right dominant side Monoplegia of upper limb affecting left dominant side Monoplegia of upper limb affecting right nondominant side Monoplegia of upper limb affecting left nondominant side Monoplegia, unspecified affecting right dominant side Monoplegia, unspecified affecting left dominant side Monoplegia, unspecified affecting right nondominant side Monoplegia, unspecified affecting left nondominant side Paralytic syndrome, unspecified Brain death Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating other procedure Accidental puncture and laceration of other nervous system organ or structure during a nervous system procedure Accidental puncture and laceration of other nervous system organ or structure during other procedure

CMS Limitations Guide ? Radiology Services

G97.51

G97.52

H34.01 H34.02 H34.03 H34.11 H34.12 H34.13 H34.211 H34.212 H34.213 H34.231 H34.232 H34.233 H34.811 H34.812 H34.813 H34.821 H34.822 H34.823 H34.831 H34.832 H34.833 H34.9 H35.061 H35.062 H35.063 H35.82 H47.011 H47.012 H47.013 H53.121 H53.122 H53.123 H53.131 H53.132

Postprocedural hemorrhage and hematoma of a nervous system organ or structure following a nervous system procedure Postprocedural hemorrhage and hematoma of a nervous system organ or structure following other procedure Transient retinal artery occlusion, right eye Transient retinal artery occlusion, left eye Transient retinal artery occlusion, bilateral Central retinal artery occlusion, right eye Central retinal artery occlusion, left eye Central retinal artery occlusion, bilateral Partial retinal artery occlusion, right eye Partial retinal artery occlusion, left eye Partial retinal artery occlusion, bilateral Retinal artery branch occlusion, right eye Retinal artery branch occlusion, left eye Retinal artery branch occlusion, bilateral Central retinal vein occlusion, right eye Central retinal vein occlusion, left eye Central retinal vein occlusion, bilateral Venous engorgement, right eye Venous engorgement, left eye Venous engorgement, bilateral Tributary (branch) retinal vein occlusion, right eye Tributary (branch) retinal vein occlusion, left eye Tributary (branch) retinal vein occlusion, bilateral Unspecified retinal vascular occlusion Retinal vasculitis, right eye Retinal vasculitis, left eye Retinal vasculitis, bilateral Retinal ischemia Ischemic optic neuropathy, right eye Ischemic optic neuropathy, left eye Ischemic optic neuropathy, bilateral Transient visual loss, right eye Transient visual loss, left eye Transient visual loss, bilateral Sudden visual loss, right eye Sudden visual loss, left eye

CMS Limitations Guide ? Radiology Services

H53.133 H53.431 H53.432 H53.433 H53.451 H53.452 H53.453 H53.461 H53.462 H53.47 H53.481 H53.482 H53.483 H81.01 H81.02 H81.03 H81.41 H81.42 H81.43 H93.11 H93.12 H93.13 I60.01 I60.02 I60.11 I60.12 I60.21 I60.22 I60.31 I60.32 I60.4 I60.51 I60.52 I60.6 I60.8 I61.0 I61.1

Sudden visual loss, bilateral Sector or arcuate defects, right eye Sector or arcuate defects, left eye Sector or arcuate defects, bilateral Other localized visual field defect, right eye Other localized visual field defect, left eye Other localized visual field defect, bilateral Homonymous bilateral field defects, right side Homonymous bilateral field defects, left side Heteronymous bilateral field defects Generalized contraction of visual field, right eye Generalized contraction of visual field, left eye Generalized contraction of visual field, bilateral Meniere's disease, right ear Meniere's disease, left ear Meniere's disease, bilateral Vertigo of central origin, right ear Vertigo of central origin, left ear Vertigo of central origin, bilateral Tinnitus, right ear Tinnitus, left ear Tinnitus, bilateral Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation Nontraumatic subarachnoid hemorrhage from right middle cerebral artery Nontraumatic subarachnoid hemorrhage from left middle cerebral artery Nontraumatic subarachnoid hemorrhage from right anterior communicating artery Nontraumatic subarachnoid hemorrhage from left anterior communicating artery Nontraumatic subarachnoid hemorrhage from right posterior communicating artery Nontraumatic subarachnoid hemorrhage from left posterior communicating artery Nontraumatic subarachnoid hemorrhage from basilar artery Nontraumatic subarachnoid hemorrhage from right vertebral artery Nontraumatic subarachnoid hemorrhage from left vertebral artery Nontraumatic subarachnoid hemorrhage from other intracranial arteries Other nontraumatic subarachnoid hemorrhage Nontraumatic intracerebral hemorrhage in hemisphere, subcortical Nontraumatic intracerebral hemorrhage in hemisphere, cortical

CMS Limitations Guide ? Radiology Services

I61.3 I61.4 I61.5 I61.6 I61.8 I62.01 I62.02 I62.03 I62.1 I63.011 I63.012 I63.02 I63.031 I63.032 I63.09 I63.111 I63.112 I63.12 I63.131 I63.132 I63.19 I63.211 I63.212 I63.22 I63.231 I63.232 I63.29 I63.311 I63.312 I63.321 I63.322 I63.331 I63.332 I63.341 I63.342 I63.39 I63.411

Nontraumatic intracerebral hemorrhage in brain stem Nontraumatic intracerebral hemorrhage in cerebellum Nontraumatic intracerebral hemorrhage, intraventricular Nontraumatic intracerebral hemorrhage, multiple localized Other nontraumatic intracerebral hemorrhage Nontraumatic acute subdural hemorrhage Nontraumatic subacute subdural hemorrhage Nontraumatic chronic subdural hemorrhage Nontraumatic extradural hemorrhage Cerebral infarction due to thrombosis of right vertebral artery Cerebral infarction due to thrombosis of left vertebral artery Cerebral infarction due to thrombosis of basilar artery Cerebral infarction due to thrombosis of right carotid artery Cerebral infarction due to thrombosis of left carotid artery Cerebral infarction due to thrombosis of other precerebral artery Cerebral infarction due to embolism of right vertebral artery Cerebral infarction due to embolism of left vertebral artery Cerebral infarction due to embolism of basilar artery Cerebral infarction due to embolism of right carotid artery Cerebral infarction due to embolism of left carotid artery Cerebral infarction due to embolism of other precerebral artery Cerebral infarction due to unspecified occlusion or stenosis of right vertebral arteries Cerebral infarction due to unspecified occlusion or stenosis of left vertebral arteries Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries Cerebral infarction due to thrombosis of right middle cerebral artery Cerebral infarction due to thrombosis of left middle cerebral artery Cerebral infarction due to thrombosis of right anterior cerebral artery Cerebral infarction due to thrombosis of left anterior cerebral artery Cerebral infarction due to thrombosis of right posterior cerebral artery Cerebral infarction due to thrombosis of left posterior cerebral artery Cerebral infarction due to thrombosis of right cerebellar artery Cerebral infarction due to thrombosis of left cerebellar artery Cerebral infarction due to thrombosis of other cerebral artery Cerebral infarction due to embolism of right middle cerebral artery

CMS Limitations Guide ? Radiology Services

I63.412 I63.421 I63.422 I63.431 I63.432 I63.441 I63.442 I63.49 I63.511 I63.512 I63.521 I63.522 I63.531 I63.532 I63.541 I63.542 I63.59 I63.6 I63.8 I65.01 I65.02 I65.03 I65.1 I65.21 I65.22 I65.23 I65.8 I66.01 I66.02 I66.03 I66.11 I66.12 I66.13 I66.21 I66.22 I66.23 I66.3

Cerebral infarction due to embolism of left middle cerebral artery Cerebral infarction due to embolism of right anterior cerebral artery Cerebral infarction due to embolism of left anterior cerebral artery Cerebral infarction due to embolism of right posterior cerebral artery Cerebral infarction due to embolism of left posterior cerebral artery Cerebral infarction due to embolism of right cerebellar artery Cerebral infarction due to embolism of left cerebellar artery Cerebral infarction due to embolism of other cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery Cerebral infarction due to cerebral venous thrombosis, nonpyogenic Other cerebral infarction Occlusion and stenosis of right vertebral artery Occlusion and stenosis of left vertebral artery Occlusion and stenosis of bilateral vertebral arteries Occlusion and stenosis of basilar artery Occlusion and stenosis of right carotid artery Occlusion and stenosis of left carotid artery Occlusion and stenosis of bilateral carotid arteries Occlusion and stenosis of other precerebral arteries Occlusion and stenosis of right middle cerebral artery Occlusion and stenosis of left middle cerebral artery Occlusion and stenosis of bilateral middle cerebral arteries Occlusion and stenosis of right anterior cerebral artery Occlusion and stenosis of left anterior cerebral artery Occlusion and stenosis of bilateral anterior cerebral arteries Occlusion and stenosis of right posterior cerebral artery Occlusion and stenosis of left posterior cerebral artery Occlusion and stenosis of bilateral posterior cerebral arteries Occlusion and stenosis of cerebellar arteries

CMS Limitations Guide ? Radiology Services

I66.8 I67.0 I67.1 I67.2 I67.4 I67.6 I67.7 I67.81 I67.82 I67.841 I67.848 I67.89 I68.2 I69.020 I69.021 I69.022 I69.023 I69.090 I69.091 I69.092 I69.093 I69.120 I69.121 I69.122 I69.123 I69.190 I69.191 I69.192 I69.193 I69.220 I69.221 I69.222 I69.223 I69.290 I69.291 I69.292 I69.293

Occlusion and stenosis of other cerebral arteries Dissection of cerebral arteries, nonruptured Cerebral aneurysm, nonruptured Cerebral atherosclerosis Hypertensive encephalopathy Nonpyogenic thrombosis of intracranial venous system Cerebral arteritis, not elsewhere classified Acute cerebrovascular insufficiency Cerebral ischemia Reversible cerebrovascular vasoconstriction syndrome Other cerebrovascular vasospasm and vasoconstriction Other cerebrovascular disease Cerebral arteritis in other diseases classified elsewhere Aphasia following nontraumatic subarachnoid hemorrhage Dysphasia following nontraumatic subarachnoid hemorrhage Dysarthria following nontraumatic subarachnoid hemorrhage Fluency disorder following nontraumatic subarachnoid hemorrhage Apraxia following nontraumatic subarachnoid hemorrhage Dysphagia following nontraumatic subarachnoid hemorrhage Facial weakness following nontraumatic subarachnoid hemorrhage Ataxia following nontraumatic subarachnoid hemorrhage Aphasia following nontraumatic intracerebral hemorrhage Dysphasia following nontraumatic intracerebral hemorrhage Dysarthria following nontraumatic intracerebral hemorrhage Fluency disorder following nontraumatic intracerebral hemorrhage Apraxia following nontraumatic intracerebral hemorrhage Dysphagia following nontraumatic intracerebral hemorrhage Facial weakness following nontraumatic intracerebral hemorrhage Ataxia following nontraumatic intracerebral hemorrhage Aphasia following other nontraumatic intracranial hemorrhage Dysphasia following other nontraumatic intracranial hemorrhage Dysarthria following other nontraumatic intracranial hemorrhage Fluency disorder following other nontraumatic intracranial hemorrhage Apraxia following other nontraumatic intracranial hemorrhage Dysphagia following other nontraumatic intracranial hemorrhage Facial weakness following other nontraumatic intracranial hemorrhage Ataxia following other nontraumatic intracranial hemorrhage

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