Radiology Coding Alert

Following descriptor examples may not be enough to satisfy your payer.

Your practice may use ankle/brachial indices (ABIs) to help diagnose some of the 8 million Americans who have peripheral arterial disease. But if you miss CPT's guidance on hardcopies for noninvasive arterial studies, you could be headed for trouble.

Work your way through these five important rules to keep your accuracy rate at its best.

Take a close look at the descriptors for these noninvasive arterial study codes:

• 93922 -- Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement)

• 93923 -- Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia).

The key distinction is that you should use 93922 for a limited exam performed at one level of each leg, for example, and 93923 for an exam of multiple levels of each leg, says Stacie L. Buck, RHIA, CCS-P, LHRM, RCC, CIC, president and senior consultant of RadRx in Stuart, Fla.

'Segmental' tip: For 93923, you may run across the terms multiple, various, or segmental. For example, ACR Coding Source (January/February 2007) explains that radiologists may perform the test either on a single level "or at segmental (various) limb levels."

You may even hear the equipment used to perform the studies referred to as "segmental machines," says Bruce W. Hammond, CRA, CNMT, executive vice president of Diagnostic Health Services, which serves more than a dozen states.

If the radiologist performs complete multiple-level bilateral studies of the arms and legs, coders often wonder whether one or two units are appropriate. Solution: You should report two units of 93923.

AMA's CPT Assistant (June 2001) explains that the use of the word "or" in the descriptor (... studies of upper or lower extremity arteries ...) means that you should report 93923 once for the arms and once for the legs.

The same rule applies to 93922: single-level bilateral studies of the arms and legs merit two units of 93922.

You may sometimes see the radiologist perform a study on only one side. Both 93922 and 93923's descriptors specify "bilateral."

As a result, if you perform a unilateral upper or lower extremity physiologic arterial study, you should append modifier 52 (Reduced services) to 93922 or 93923. This modifier informs the payer that the radiologist did not perform the full service stated in the descriptor.

The ABI is the most common of these physiologic studies and measures blood pressure at the ankle and elbow using a Doppler stethoscope. Careful: Code 93922's descriptor refers to "ankle/brachial indices." But if your radiologist uses a handheld device that doesn't produce a hardcopy, you should not report 93922.

CPT guidelines for Noninvasive Vascular Diagnostic Studies state that the "use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered to be part of the physical examination of the vascular system, and is not reported separately."

You'll find the same rule applied in the ACR Coding Source (January/February 2007), Buck points out.

Here's why: Providers use these handheld Dopplers in physician offices to listen to the carotid arteries and infant hearts in utero, notes Hammond. The provider uses them just to listen -- "they are not designed to provide diagnostic information," he explains.

What to do: Before you use 93922 or 93923, be sure you meet these CPT guideline requirements:

"Vascular studies include patient care required to perform the studies, supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided."

5. Dig Into LCD for Additional Requirements

Protect yourself: "Everyone needs to check their own LCD [local coverage determination] on these studies," Buck says.

93922 example: Payers may not consider an ABI alone sufficient for 93922. For example, "93922 must include the ABIs and at least one of the other elements of the code," states Noridian's LCD, "Noninvasive Peripheral Arterial Studies (L24339)."

You should include an ABI in office visit services when you perform it without other vascular studies, the LCD states.

Payoff: The Medicare fee schedule lists 3.34 transitioned nonfacility total relative value units (RVUs) for 93922. Multiply that by the 36.0666 2009 conversion factor, and you see Medicare pays roughly $120 for 93922, before adjusting for regional differences.

93923 example: Code 93923 may have added rules, too: "93923 must include the segmental blood pressure measurements with 1), one of the following: segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, or 2), one of the following; measurements with postural provocative tests, measurements with reactive hyperemia."

Payoff: Report 93923 correctly, and its 5.16 transitioned nonfacility RVUs mean you'll receive roughly $186.

ICD-9 tip: Your LCD may also offer diagnosis codes that support medical necessity for these studies.

For example, the Noridian LCD lists several diagnoses that support the studies, such as 440.21 (Atherosclerosis; of native arteries of the extremities; atherosclerosis of the extremities with intermittent claudication).