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Basic about Cpt Code 93923 & 92922

CPT codes in Radiology coding are little difficult to learn and apply. Here, we are dealing with codes, which have high dollar value, so it is very important to understand the main concept behind procedure codes. I have given many tips for coding different CPT codes and today also we will learn few more coding tips. So, we are here to know about CPT code 93923, which is very confusing while coding radiology charts.

Cpt Code 93923 has a brother with CPT code 93922. These CPT codes are used to code the vascular procedure codes. We have learnt previously coding Cpt code for Ultrasound aorta, Ultrasound renal and Ultrasound abdomen studies. There is very little difference between 93922, 93923 & 93924 CPT codes, which generally confuses the medical coders while coding charts. So, first we will just check out the code description for CPT code 93923 and 93922.

The two basic modalities of evaluation are:
1. The indirect methods (e.g. Ankle/Brachial Index (ABI), segmental limb pressures, transcutaneous oxygen tension measurement (TcPO2), CW bi-dimensional Doppler and plethysmographic waveforms) that provide information regarding functional severity of disease.
2. The direct method of evaluation which is color-duplex imaging (CDI), the duplex scan that provides more specific anatomic and physiologic information.

Ankle/Brachial Index
The most common test is the Ankle-Brachial Index (ABI). This test measures the blood pressure at the ankle and elbow, and is performed using a Doppler stethoscope. While inflating cuffs placed on arms and legs, the technician positions the Doppler at a 45-degree angle to three arteries: the dorsalis pedis, posterior tibia, and brachial of the right and left sides.

Single Level Pressure and Physiologic Waveform
Blood pressure and physiologic waveform (Doppler velocity signal or plethysmography tracing) recordings are obtained bilaterally at a single level (usually the ankle).

Segmental Pressure and Physiologic Waveform
Blood pressures at various limb levels are measured to identify areas of regional hypotension. Physiologic waveforms(Doppler velocity signals or plethysmography tracings) are recorded at the same level to localize the level of disease to the inflow/outflow or runoff vessels

• 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).

93924– Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at rest with ankle/brachial indices immediately after and at timed intervals following performance of a standardized protocol on a motorized treadmill plus recording of time of onset of claudication or other symptoms, maximal walking time, and time to recovery) complete bilateral study

Do not report 93924 with CPT code 93922 & 93923

The CPT codes are based on the ABI (Ankle Branchial Index) test. The ABI test is done to check for any risk related to Peripheral Artery Disease (PAD). In this condition the arteries of extremities, legs or arms, are narrowed or blocked. Patients suffering from peripheral artery disease are more at a risk of heart attack, leg pain, poor circulation of blood and stroke.

Concept about Cpt code 93923 and 93922

Now, as we see, the description for CPT code 93922 involves noninvasive study of either both Lower extremity or upper extremity arteries at a single level. A single level study can be evaluation of Doppler waveform analysis, volume plethysmography and/or transcutaneous oxygen tension measurement at each ankle. Same single level evaluation can be done on upper extremities as well. Moreover, when both the upper and lower extremities are studied we have to use twice 93922 along with 59 or XS modifier depending on the client guidelines. So, hope you have understood when to code CPT code 93922 in non-invasive studies.

Cpt Code 93923 noninvasive studies are done on multiple levels. This is major difference between CPT code 93922 and 93923. Cpt Code 93923 involves study of either upper or lower extremities at multiple levels. So, if a multiple level study can be evaluation of segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests and/or measurements with reactive hyperemia. So, here majorly the segmental pressure measurement gets included with CPT code 93923. Same goes with upper extremities. And when both the Upper and Lower extremities are evaluated we will use twice 93923 along with 59 or XS modifier depending on the client coding guideline. Because the code descriptions are stated as bilateral exams, use modifier 52 for reduced services if the study is only done on one side.

The correct way to report bilateral procedures of both upper and lower extremities is to report the code twice on separate line items, one with modifier -59 (distinct procedural service), according to the NCCI Manual. It is not correct reporting to just append modifier -59 to the line item with two units; it should not override the MUE, because the units on the line item are two. Chapter 11 of the NCCI Manual states:

CPT codes 93922 and 93923 describe bilateral noninvasive physiologic studies of the upper or lower extremities. The MUE value for each of these codes is one since it is unlikely that this testing would be performed on both upper and lower extremities on the same date of service. In unusual situation where testing on both the upper and lower extremities are performed on the same date of service, the appropriate code may be reported on two lines of a claim, each one unit of service and modifier –59 appended to the code on one of the claim lines.

When to use CPT code 93923 and 93922

First of all just check the report for Ankle brachial Index (ABI). If it is done then look for the procedure codes description for code 93923 and 93922. Now check the documentation of the report and search for the presence of segmental pressure in the report. If the report documents the segmental pressure, we can go ahead and code CPT code 93923 and if not we will code 93922. I generally look for these things if I have to code any of these CPT codes. However, the more you come across such reports, the more your concepts become clear. So, do check the report properly before using CPT code 93922 and 93923.

Covered peripheral arterial study testing methods include duplex scans; Doppler waveform or spectral analysis; volume, impedance or strain gauge plethysmography; and transcutaneous oxygen tension measurement.

Non-covered peripheral arterial study testing methods include thermography, mechanical oscillometry, inductance or capacitance plethysmography, photoelectric plethysmography, differential plethysmography, and light reflective rheography.

Additional Code Information

PC/TC Indicator (26): 1 = Diagnostic Tests for Radiology Services

Multiple Procedures (51): 6 = Subject to 25% reduction of the second highest and subsequent procedures to the TC of diagnostic cardiovascular services

Bilateral Surgery (50): 2 = 150% payment adjustment does not apply

Physician Supervision: 09 = Concept does not apply

Assistant Surgeon (80,82): 0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted

Co-Surgeons (62): 0 = Co-surgeons not permitted for this procedure

Team Surgery (66): 0 = Team surgeons not permitted for this procedure

Diagnostic Imaging Family: 99 = Concept does not apply

Indications:

Non-invasive peripheral arterial examinations, performed to establish the level and/or degree of arterial occlusive disease, are medically necessary if (1) significant signs and/or symptoms of possible limb ischemia are present and (2) the patient is a candidate for invasive/surgical therapeutic interventions. Acute ischemia is characterized by the sudden onset of severe pain, coldness, numbness and pallor of the extremity. Chronic ischemia can be manifested by intermittent claudication, pain at rest, diminished pulse, ulceration, and gangrene.

A routine history and physical examination, which includes ankle/brachial indices (ABIs), can readily document the presence or absence of ischemic disease in the majority of cases. It is not medically necessary to proceed beyond the physical examination for minor signs and symptoms such as hair loss, absence of a single pulse, relative coolness of a foot, shiny thin skin, or lack of toe nail growth unless related signs and/or symptoms are present which are severe enough to require possible invasive intervention.

An ABI is not a reimbursable procedure by itself; rather, ABI may be reimbursed when derived from a more comprehensive procedure which includes a permanent chart copy of the measured pressures and waveforms in the examined vessels. An ABI should be abnormal, e.g., and must be accompanied by another appropriate indication before proceeding to more sophisticated or complete studies, except in patients with severe diabetes or uremia resulting in medial calcification as demonstrated by artifactually elevated ankle blood pressure.

Peripheral artery studies may be considered medically necessary if the following signs and symptoms are present:

Claudication of such severity that it interferes significantly with the patient’s occupation or lifestyle, or claudication with inability to stress the patient;
Rest pain (typically including the forefoot), usually associated with absent pulses, which becomes increasingly severe with elevation and diminishes with placement of the leg in a dependent position;
Tissue loss defined as gangrene or pre-gangrenous changes of the extremity, or ischemic ulceration of the extremity occurring in the absence of pulses;
Aneurysmal disease;
Evidence of thromboembolic events;
Blunt or penetrating trauma (including complications of diagnostic and/or therapeutic procedures); and/or
Follow-up of grafts or other vascular intervention

Pre-surgical conduit assessment of the upper extremity/radial artery(ies) may be performed prior to use in coronary artery bypass grafting (CABG) or as other arterial conduits.

Limitations:

Peripheral artery studies may not be considered medically necessary if only the following signs and symptoms are present:

Continuous burning of the feet (considered to be a neurologic symptom);
Leg pain, nonspecific (M79.606) and pain in limb (M79.669) as single diagnoses are too general to warrant further investigation unless they can be related to other signs and symptoms;
Edema rarely occurs with arterial occlusive disease unless it is in the immediate postoperative period, in association with another inflammatory process or in association with rest pain; and/or
Absence of pulses in minor arteries, e.g., dorsalis pedis or posterior tibial, in the absence of symptoms. The absence of pulses is not an indication to proceed beyond the physical examination unless it is related to other signs and/or symptoms.

Duplex scanning and physiologic studies may be reimbursed during the same encounter if the physiologic studies are abnormal and/or to evaluate vascular trauma, thromboembolic events or aneurysmal disease, if the physician/provider can document medical necessity in the patient’s medical record.

In general, non-invasive studies of the arterial system are to be utilized when invasive correction is contemplated or severity of findings dictate non-invasive study follow-up, but not for following non-invasive medical treatment regimens. The latter may be followed with physical findings and/or progression or relief of signs and/or symptoms. Screening of the asymptomatic patient is not covered by Medicare.

Sample coded chart for CPT code 93922, 93923 & 93924

EXAM: US ARTERIAL LOWER W EXERCISE & DUPLEX

REASON FOR STUDY: Peripheral vascular disease (disorder), :

CLINICAL HISTORY:
Peripheral vascular disease. Pain in calves while running with intermittent numbness and tingling.

TECHNIQUE:
The study was performed in an ACR accredited facility. Ultrasound of bilateral lower extremities was performed using grayscale, color and spectral Doppler.

FINDINGS:
RIGHT LOWER EXTREMITY (velocities in cm/s, waveform):
Grayscale imaging demonstrates minimal atherosclerotic calcified plaque in right lower extremity arteries.
External iliac artery: 283, triphasic
Common femoral artery: 176, triphasic
Profunda artery: 149, triphasic
Superficial femoral artery proximal: 130, triphasic
Superficial femoral artery mid: 119, triphasic
Superficial femoral artery distal: 105, triphasic
Popliteal artery: 71, triphasic
Posterior tibial artery: 64, triphasic
Dorsalis pedis artery: 30, triphasic
Ankle-brachial index: 1.32 at rest, 1.31 after walking for 8 min at brisk
pace. Patient had no pain during walking but had some numbness and tingling
in lower legs.

LEFT LOWER EXTREMITY (velocities in cm/s, waveform):
Grayscale imaging demonstrates minimal atherosclerotic calcified plaque in
left lower extremity arteries.
External iliac artery: 210, triphasic
Common femoral artery: 128, triphasic
Profunda artery: 79, triphasic
Superficial femoral artery proximal: 101, triphasic
Superficial femoral artery mid: 98, triphasic
Superficial femoral artery distal: 100, triphasic
Popliteal artery: 54, triphasic
Posterior tibial artery: 85, triphasic
Dorsalis pedis artery: 39, triphasic
Ankle-brachial index: 1.28 at rest, 1.37 after walking for 8 min at brisk
pace. Patient had no pain during walking but had some numbness and tingling in
lower legs.