More payers are applying increased scrutiny to diagnostic services, with diagnostic imaging at the forefront of this trend. Diagnostics have gotten a bad rap over the last several years as the target in several whistleblower cases and audit recoveries requiring several million dollars in refunds collectively. Medicare of FL routinely requests medical records for these services, and no wonder as Florida is a hotbed of audit activity. They have also added some very clear and detailed language in their current LCD that has prompted me to dust off this subject and revisit some of the dos and don’ts on diagnostics.
There are 2 distinct hurdles that must be crossed for a diagnostic service to be supported, the first being the medical necessity for ordering the service, and the second being the proper execution and reporting of the service. I don’t presume to tell any provider what services they should order for the good of their patients, just what the insurances will cover, which are two distinctly different topics.
Reporting a level of diagnostic CPT for veins is determined by how many vessels were imaged, if the service is unilateral or bilateral, and were both the deep and superficial systems addressed? On codes 93970 and 93971, the distinction is greater than just unilateral or bilateral. 93970 is defined as a complete bilateral study, and as such must meet this definition exactly to be reported. 93971 is a unilateral or limited study, and can be used for a limited bilateral service as well as a unilateral. The ACR has excellent reporting guides as does ICAVL for each of these studies. Medicare of Florida has also added a clear definition to their LCD that states:
“For a complete examination, all deep veins of the leg are examined, including the common femoral, femoral, deep femoral, popliteal, peroneal, soleal, gastrocnemial, anterior, and posterior tibial veins. The superficial veins are then evaluated including the GSV, the SSV, the accessory saphenous veins, perforating veins, and tributary veins. Six components that should be included in a complete duplex scanning examination for CVD are (1) visibility, (2) compressibility, (3) venous flow, including measurement of the duration of reflux, (4) augmentation, (5) phasicity, and (6) vein size. The cutoff value of 500 ms is for the saphenous, tibial, deep femoral, and perforating vein incompetence, and 1 second for femoral and popliteal vein incompetence.”
If even one element is left out, or not addressed in the interpretation, then the study is not complete and has to be reported with 93971.
That brings us to Medical Necessity.
Most payers have clear guidelines as to what exactly defines medical necessity but there are always some standard similarities. One item that seems to be missed is when a complete vs a limited study is warranted. Payers have been denying payment for complete studies when they have reached a frequency that they feel is more than would be necessary in any given timeframe, typically a 12 month period.
The rationale behind this is that you, the provider, have already performed a complete study and made an assessment of the patient’s condition based upon this study. While care is being performed it would not be indicated to re-diagnose the patient, and instead only studies ordered to monitor the patient’s progress would be necessary. Hence, continuously ordering and billing for complete studies would be considered unnecessary testing and potentially up-coding for reimbursement with no clinical reason to back up the services.
Medicare of Florida has also added this language to their policy:
“It is the expectation that one complete bilateral duplex scan will precede the development of the plan of care. One unilateral (or bilateral if both extremities are treated) study post treatment may be performed if supported in the plan of care.”
So be aware that if you have been receiving denials on your 93970 codes for maximum frequency or have had your US reports requested by your contracted insurance companies, this may be the reason. If not, like all things insurance, you may see this trend on the rise, so a revision of how studies are reported may need to be assessed in your practice. The golden rule is only perform what is necessary, and only report what you performed.
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