Radiology Coding Alert

The incidence of erectile dysfunction (ED) is increasing in the United States. This has resulted in greater demand for diagnostic tests that identify underlying causes and suggest treatments with the greatest likelihood of success. Among these tests are several radiological studies that may not be reimbursable if coded incorrectly. But with a firm grasp on coding policies, radiology coders can effectively maximize reimbursement for erectile dysfunction studies.

ED currently affects 15 to 25 percent of American men older than 65. Medical professionals predict this number will grow as the average age of the population rises. The number of younger men suffering from the condition is also mounting because ED is recognized more widely as a side effect of diseases like diabetes and hypertension.

Likewise, radiology practices report an escalating number of patients being seen for noninvasive vascular diagnostic studies, which allow the ultrasound technologist and radiologist to assess penile blood flow. Reimbursement policies for these scans, however, vary widely from region to region and carrier to carrier.

Coding Duplex Scanning

Duplex scanning of penile blood flow has become the diagnostic method of choice, according to Richard Brebner, BS, RDMS, RDCS, RVT, vice president and technical director for Ultrasound Services Inc., which provides diagnostic ultrasound services in Pennsylvania, Delaware and New Jersey. These studies are described in CPT Codes 93980 (duplex scan of arterial inflow and venous outflow of penile vessels; complete study) and 93981 ( ... follow-up or limited study).

We are seeing more men younger than 60 with erectile dysfunction, Brebner says. The underlying reason for the condition may be either psychosexual or organic. The duplex scan is performed to evaluate how well the blood is flowing to the penis to create and maintain an erection. Obviously, if there is a stenosis or blockage of the artery, we know there is an organic cause and can treat the patient accordingly.

During the study, the patient is injected with a vasoactive agent to force blood into the penis. An ultrasound will display a two-dimensional structure of the vessels and motion with time. In addition, the duplex scan will include Doppler ultrasound signal documentation with spectrum analysis and color flow velocity mapping or imaging.

The procedure is coded 93980, and the injection would most likely be bundled into the procedure, according to Susan Callaway-Stradley, CPC, an independent coding consultant and educator in North Augusta, S.C.

Although there are injection and drug codes that may be assigned in addition to 93980 in some instances (i.e., CPT 54235 , injection of corpora cavernosa with pharmacologic agent[s] [e.g., papaverine, phentolamine]; and J2440, injection, papaverine HCl, up to 60 mg), Callaway-Stradley notes that Medicare places strict frequency limitations on how often they are used for the diagnosis of ED usually only once. In addition, coders will want to check with their commercial insurance companies to make sure that the injection is not bundled into the duplex procedure, she cautions.

In some instances, a more traditional Doppler ultrasound (76999, unlisted ultrasound procedure) will be performed. This service, Callaway-Stradley notes, will provide diagnostic evaluation of soft tissue, rather than blood flow.

Historically, penile plethysmography (54240) has been used to diagnose ED, Brebner says. This technique includes volume measurement procedures like air, impedance or strain gauge methods. This is seen as an antiquated tool, and is used infrequently, he adds. Not surprisingly, few carriers cover this procedure.

Reimbursement for Duplex Scans Varies

Although the diagnostic technology is available, many radiology coders will encounter problems with reimbursement. A review of local Medicare policies reveals dramatic variances in payment practices. Some carriers disallow payment for 93980 altogether, others accept it under limited circumstances, and still others are quite liberal in their acceptance.

HGS Administrators, the Medicare carrier in Pennsylvania, for example, states in its local medical review policy (LMRP) on ED that reporting of duplex codes 93980 and 93981 will be denied since they are thought to have no therapeutic implications and are deemed to be not medically reasonable or necessary for these conditions.

Empire Medicare Services echoes this sentiment in its policy covering New Jersey, but in New York allows radiologists to report 93980 and 93981 when the scan is conducted on patients who sustain a documented groin injury and if a surgical procedure on the pudendal vessels is being considered.

Palmetto GBA in South Carolina, on the other hand, outlines specific circumstances when duplex ultrasounds are payable. Codes 93980 and 93981 are allowable when performed on patients who:

have a lifetime history of ED;
demonstrate no more than two vascular risk factors that
include age greater than 65 years, hypertension,
diabetes, lipid abnormalities, obesity, cigarette
consumption, atherosclerotic disease in any vessel, and
medications that produce impotence; and
patients in whom pharmacologic injections are
inadequate.

Blue Cross/Blue Shield, serving Kansas, Nebraska and parts of Missouri, allows the scans when part of a stepwise, documentation-based, progressively intensive approach to the investigation of ED. The carrier views tests with pharmacological agents (i.e., injections that may be self-administered to produce erections) as a threshold study, followed by other modalities to eliminate anxiety as a cause of ED. When these conditions are met, 93980 to assess blood flow will be covered if the physician has determined that erectile response to injection is poor or less than satisfactory, and that anxiety is a strong operational factor in this failure. Under this policy, 93981 is allowable if the patient is identified as a strong candidate for vascular surgery.

Likewise, all these carriers cover 93980 and 93981 only with limited diagnosis codes. Most carriers recognize 302.72 (psychosexual dysfunction, with inhibited sexual excitement [impotence]) and 607.84 (other specified disorders of penis, impotence of organic origin).

It would be wise for coders to stay in close communication with local carriers to make sure they understand the restrictions on these procedure codes, Callaway-Stradley advises.