Internal Medicine Coding Alert

Question: When an internist makes a definitive diagnosis of peripheral vascular disease (PVD), I code the study with 93965 and 443.9. If the patient does not have PVD, I use an ICD-9 that describes what's going on, such as leg pain (729.5) or unspecified circulatory system disorder (459.9). Medicare denies payment for 93965 based on the diagnosis. Do you have any suggestions?


Alabama Subscriber

Answer: Counting different noninvasive peripheral studies as the same procedure may be at the heart of your problem. The definitive diagnosis (PVD: 443.9, Peripheral vascular disease, unspecified) that you use in conjunction with these tests is a covered ICD-9 code for arterial studies (93922-93931), not for venous studies (93965-93971). Check whether in these cases you are using the wrong CPT code to describe the IM-ordered study. The other diagnoses that you mention, however, are associated with venous studies.

Problem: Your Medicare carrier's local coverage determination (LCD) lists only 729.5 (Pain in limb) as an acceptable diagnosis for 93965 (Non-invasive physiologic studies of extremity veins, complete bilateral study [e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography]). Cahaba Government Benefit Administrators (Alabama Medicare Part B) does not include 459.9 (Unspecified circulatory system disorders) as a covered ICD-9 code for 93965.

The carrier may, however, impose additional requirements when using a diagnosis of leg pain. For instance, Cahaba GB's Mississippi and Georgia LCDs also list 729.5 as a covered diagnosis with extremity study code 93965, but require an additional diagnosis. "Leg pain, nonspecific and pain in limb as single diagnosis are too general to warrant further investigation unless they can be related to other signs and symptoms," according to Cahaba GB's Georgia's LCD for Noninvasive Vascular Studies.

Finally: Instead of using 459.9, see if you can code a more specific circulatory system disorder. Many carriers will not cover unspecified diagnoses, such as 459.9. If the study's results allow the internist to make a diagnosis of postphlebitic syndrome or vein compression, you should assign 459.10-459.2. Cahaba GB considers these covered diagnoses for venous studies (93965-93971).