Radiology Coding Alert
Match Up Arterial, Venous Diagnoses When Reporting Extremity Ultrasounds
Initial Symptoms Reveal Study Type
"The arterial system performs a much different function than the venous system," says Richard Brebner, BS, RDMS, RDCS, RVT, vice president and technical director for Ultrasound Services Inc., which provides diagnostic ultrasound services in Penn-sylvania, Delaware and New Jersey. "Arteries move blood away from the heart to the extremities, while the veins return the blood from the extremities back to the heart." Because these functions are so different, interference with blood flow in one system will produce much different symptoms from interference in the other. These disparities, which will be outlined in the medical record, can help coders immediately determine whether they should consider arterial or venous ultrasound codes. (See table on page 19.)
Signs that indicate blood is not reaching the extremities because of arterial insufficiency include decreased pulses, a bluish cast to the skin on the fingers or toes, for instance and skin that is cold to the touch. When coders see these symptoms in the physician documentation, they should immediately turn to codes describing arterial ultrasounds (93922-93930). However, if an occlusion or blood clot occurs in a vein, blood pools, causing swelling and redness. The skin becomes warm to the touch. Radiologist documentation of these indications should cause coders to consider venous ultrasound codes (93965-93971).
Note: In some cases, severe venous occlusion may also compromise the arterial inflow. When this clinical condition, called phlegmasia cerulea albicans, is suspected, a venous study may be performed instead of or in addition to the arterial study.
Study Type Drives Diagnosis Coding
Because the symptoms indicate problems in either the arterial or venous system, diagnosis coding is equally unequivocal, says Pat Kirkham, RDMS, sonographer with Randallwood Radiology, a private practice of three radiologists in St. Charles, Ill. "There are specific diagnoses that relate to conditions of the arteries and others that relate only to the veins," Kirkham says. Coders must be sure to match the correct symptoms with the correct diagnosis code. These must tie in with the study performed or the claim will certainly be denied, Kirkham adds.
The arterial diagnoses codes for circulation problems interfering with blood getting to the extremities include:
On the other hand, codes for venous diseases and conditions are:
A number of conditions might affect both the arterial and venous systems, Brebner notes, and these may support medical necessity for diagnostic ultrasound in either system. The codes include the 903.x series (Injury to blood vessels of upper extremity) and the 904.x series (Injury to blood vessels of lower extremity and unspecified sites).
Arterial Studies Defined
As clear-cut as the diagnostic codes are, the procedure codes describing diagnostic ultrasounds of the extremities are equally distinct, Kirkham says. Seven codes describe arterial studies:
The initial study performed is often 93923. "The intent of the study is to investigate how well the blood is flowing between two different points in an extremity," Brebner explains. "This initial Doppler which uses sound waves to measure blood flow will confirm that the flow is diminished. It is likely the referring physician will order additional studies so we can pinpoint precisely where the problem is." In addition, segmental blood pressure measurements can quantify the severity of the disease.
He adds that 93922 is similar to 93923. Code 93922 provides the ankle/brachial index (ABI), where arterial pressures are measured at the ankle and the brachial artery, with one divided into the other. This index quantifies the degree of severity of the circulation problem. Brebner notes, however, that the Correct Coding Initiative (CCI) considers 93922 a component of 93923 because a single segmental pressure analysis is when the study is performed at multiple levels. For both to be reported and paid, the physician must document the need for both studies (e.g., a full study of the lower extremities and a limited single segmental study of the upper extremities), and coders would append modifier -59 (Distinct procedural service) to 93922. However, merely reporting the ABI in addition to the multilevel segmental measurements inherent in 93923 does not allow the coding of both 93923 and 93922.
Finally, 93924 is assigned when lower-extremity arterial studies are done in conjunction with stress testing.
These three codes rely only on Doppler waveform analysis, not imaging. However, clinicians may perform studies that combine ultrasound imaging and Doppler, which are described in four specific codes.
Code 93925 is frequently used to report a study on the legs. Brebner notes that a duplex scan adds visualization and an imaging component to the Doppler waveform study. "This allows us to actually see the plaque buildup, which is causing the blockage," Brebner says. Likewise, 93926 describes a unilateral or limited duplex study of the lower extremity. CPT 93930 is assigned for duplex studies of the arms, and 93931 is assigned for a unilateral or limited duplex study of the upper extremity.
Venous Studies Defined
There are three codes describing venous studies:
Coding for venous diagnostic ultrasounds is somewhat more straightforward, Brebner points out. When only Doppler waveform technology is used without imaging, 93965 is assigned. Duplex scans using both Doppler waveform and imaging components are described with 93970 and 93971.
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