June 15, 2009

The Lowdown on Extremity Studies
By Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC
Radiology Today
Vol. 10 No. 12 P. 8

CPT codes 93922 and 93923 are assigned for bilateral upper or lower extremity arterial assessments to check blood flow in relation to a blockage. These are typically performed to establish the level and/or degree of arterial occlusive disease. There are no “pictures” or images of the study. In looking at the code descriptions closely, you’ll see that they are both bilateral, but 93923 would cover multiple levels, also referred to as “segments.”

• 93922 — Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement).

• 93923 — Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, 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).

Additional documentation of one of the following would support 93923:

• provocative functional maneuvers;

• postural provocative test measurements; or

• reactive hyperemia measurements.

If none of the above are documented, it’s most likely that the procedure should be coded to 93922.

Because the code descriptions are stated as bilateral exams, use modifier 52 for reduced services if the study is only done on one side. Additionally, because the CPT description states upper or lower extremity, you can report two units of 93922/93923 if both upper and lower studies are performed.

So where is CPT code 93924 in all this? 93924 signals non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study. 93924 is the same as 93923, with the addition of bilateral lower extremity exercise such as treadmill stress.

Duplex Scans
Duplex Doppler ultrasound uses standard ultrasound methods to produce an image of a blood vessel and the surrounding organs. In addition, a computer converts the Doppler sounds into a graph that provides information about the speed and direction of blood flow through the blood vessel being evaluated.

It’s important to note that handheld Dopplers, wherein the physician just listens and there is no hard copy output for evaluation of bidirectional blood flow, are not reportable by these codes. Those services are usually considered part of the evaluation and management service.

Duplex scans require the three pairs of codes as follows:

• Lower extremity arterial: 93925 — Duplex scan of lower extremity arteries or arterial bypass grafts, complete bilateral study; 93926 — Duplex scan of lower extremity arteries or arterial bypass grafts, unilateral or limited study.

• Upper extremity arterial: 93930 — Duplex scan of upper extremity arteries or arterial bypass grafts, complete bilateral study; 93931 — Duplex scan of upper extremity arteries or arterial bypass grafts, unilateral or limited study.

• Upper or lower extremity venous: 93970 — Duplex scan of extremity veins including responses to compression and other maneuvers, complete bilateral study; 93971 — Duplex scan of extremity veins including responses to compression and other maneuvers, unilateral or limited study.

Table 1 offers a precise view of the difference between the codes.

Study Comparison
Noninvasive physiologic studies are nonimaging studies, and duplex studies are imaging studies. Table 2 can help coders differentiate between the two exams.

Noninvasive physiologic studies are usually done initially and, if abnormal or inconclusive results are obtained, a duplex study may be warranted. Check your local coverage determinations to see what diagnoses support medical necessity for the duplex scan procedure. If your patient doesn’t have a supporting diagnosis, obtain an advance beneficiary notice.

Some consultants believe that if a duplex study such as 93925 is done and ankle/brachial indices are measured, it is appropriate to bill both 93925 and 93922 or 93923. This is justified because the equipment for noninvasive physiologic studies is different than what is required for a duplex study.

— Laureen Jandroep, OTR, CPC-EMS, CPC-H, RCC, is a natural language processing coding analyst for CodeRyte, Inc.

Table 1 (Note to Art: Please put this above the table.)

Table 2