CPT CODE 93875, 93880, 93882 – Non-Invasive Cerebrovascular Studies, Carotid Doppler

CPT code and description

93880 – Duplex scan of extracranial arteries; complete bilateral study -average fee amount -$200 -$210

93875 – Noninvasive physiologic studies of extracranial arteries, complete bilateral study (eg, periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis)

93882 – Duplex scan of extracranial arteries; unilateral or limited study

93886 – Transcranial Doppler study of the intracranial arteries; complete study

93888 – Transcranial Doppler study of the intracranial arteries; limited study

93890 – Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892 – Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

93893 – Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

INTRODUCTION:

A Duplex scan is an ultrasonic scanning procedure used to characterize the pattern and direction of blood flow in arteries or veins with the production of real-time images. While cerebrovascular ultrasound is a relatively safe and widely available modality it does have its particular shortcomings and specific indications. Obtaining a high quality study requires the interplay of a number of factors. There are established criteria that are important to consider in order to ensure reliable, interpretable and meaningful results. Complete Cerebrovascular Ultrasound studies are bilateral unless there is a specific clinical indication that warrants a limited study and investigate the common, external and internal carotid arteries as well as the vertebral arteries. 2D (Grayscale) and Doppler velocities are included.

A review of common clinical scenarios where cerebrovascular ultrasound is used follows. These scenarios are scored for appropriate use on a scale of 1-9. A median score of 7-9 indicates that this is an appropriate test for the specific indication. A median score of 4-6 indicates that there is unclear evidence as to the appropriateness of the test. A median score of 1-3 indicates that the test is not generally acceptable for the indication.

Evaluation for Cerebrovascular Disease – Potential Signs and/or Symptoms

1. * New or worsening hemispheric neurological symptoms (e.g., unilateral motor or sensory deficit, speech impairment, or amaurosis fugax) (a)
* Evaluation of transient ischemic attack or stroke A (9)
2. * Hollenhorst plaque visualized on retinal examination A (8)
3. * Lightheadedness or impaired vision in the setting of upper extremity exertion
* Evaluation for subclavian–vertebral steal phenomenon A (7)
4. * Syncope of uncertain cause after initial cardiovascular evaluation (d) U (5)
5. * Suspected symptomatic vertebrobasilar occlusive disease in A (7) the symptomatic patient (e.g., vertigo, ataxia, diplopia, dysphagia, dysarthria)
6. * Evaluation for suspected carotid artery dissection (b) A (8)
7. * Pulsatile neck mass A (8) 8.
* Cervical bruit
* No prior carotid artery assessment A (7) Surveillance After Carotid Artery Intervention 25.
* Baseline (within 1 month) after carotid intervention A (8)


LIMITED STUDY INDICATIONS (CPT code: 93882)

A limited study is indicated under the following circumstances:
1) Post intervention surveillance where the contralateral carotid is free of disease.
2) Post intervention where the contralateral carotid has less than 70% stenosis and the surveillance period on the contralateral carotid has been less than 9 month.
3) Emergent or urgent requests in the immediate postoperative or postprocedural period.

a. Cerebrovascular ultrasound is rated as Appropriate for evaluation of vertebrobasilar occlusive disease. Other Ultrasound protocols including Transcranial Doppler and other imaging modalities such as MRI or CT may be indicated.

b. Carotid Ultrasound is rated as Appropriate for Carotid artery dissection. This is in the scenario of suspected carotid dissection as a continuation of dissection of the aortic arch or ascending aorta and is Inappropriate in the setting of trauma where distal dissection and intracranial extension cannot be diagnosed by Ultrasound. CT and MRI are used in this scenario.

c. The appropriateness for cerebrovascular duplex is rated as Uncertain for all scenarios prior to cardiac surgery. This excludes patients with cerebrovascular symptoms. In patients with cerebrovascular symptoms (prior hemispheric stroke, TIA, etc.) cerebrovascular duplex would be Appropriate. Routine scanning of asymptomatic patients and particularly those without atherosclerotic comorbidities is Inappropriate.

d. The use of Carotid Duplex in the evaluation for syncope without cardiac cause is rated as Uncertain. Cerebrovascular disease is a rare cause of syncope, but can be seen in severe and usually bilateral internal carotid stenosis, in severe vertebral basilar disease and in subclavian steal syndrome. Without cardiovascular risk factors or demonstrated atherosclerotic disease elsewhere the yield of Carotid Duplex in the evaluation of syncope is very low.

e. Clinical management of asymptomatic patients with demonstrated atherosclerotic disease requires periodic ultrasound surveillance. Any follow-up in patients with a normal baseline carotid ultrasound is Inappropriate. The frequency and appropriateness of testing intervals can change in the setting of new abnormalities on a surveillance study.

f. Screening studies are Inappropriate in the setting of a low Framingham risk score. Screening studies are also Inappropriate in patients with low or intermediate Framingham risk scores who have undergone other risk assessment imaging such as carotid IMT measurement or coronary artery calcium scoring.

• Amaurosis fugax.
• Cervical bruits.
• Pulsatile neck masses.
• Follow-up of patients with proven carotid disease who are receiving medical therapy.
• Follow-up for postoperative patients following carotid endarterectomy.
• Hemispheric neurologic symptoms of stroke.
• Blunt neck trauma.
• Subclavian steal syndrome.
• Focal cerebral or ocular transient ischemic attacks (i.e., localizing symptoms, weakness of one side of the face, slurred speech, weakness of a limb, ocular ischemia).
• Preoperative evaluation of selected patients scheduled for major cardiovascular surgical procedures that, because of their clinical history and/or presentation, are at increased risk of intraoperative or perioperative stroke (dual-diagnosis required; see below).
• Evaluation of suspected dissection.

• Ocular transient ischemic attacks are defined as retinal or visual field deficits and not temporarily blurred vision.
• Episodic dizziness with symptoms typical of transient ischemic attacks may indicate reasonableness and necessity, especially when other more common sources, (e.g., postural hypotension or transiently decreased cardiac output, as demonstrated by cardiac event monitoring) have been previously excluded. Dizziness and giddiness alone are not usual indications for duplex ultrasonography of the extracranial arteries unless associated with other localizing symptoms. Although episodic dizziness/vertigo may be a symptom of Transient Ischemic Attack (TIA), the medical record should document that more common causes of dizziness/vertigo, (e.g., postural hypotension, arrhythmia, decreased cardiac output) were ruled out prior to evaluation with duplex ultrasonography. Report duplex ultrasonography of the extracranial arteries performed in clinical circumstances consistent with cerebral ischemia and when there is a strong clinical suspicion of TIA using appropriate TIA diagnosis codes.
• Headaches, other than basilar, hemiplegic and classical with intractable migraine are not indications for extracranial arterial studies.
• Since “drop attacks” or syncope are seen with vertebrobasilar or bilateral carotid artery disease, documentation in the medical record must substantiate the suspected existence of these diseases when using these codes.

• Detection of severe stenosis (>65 percent) in the major basal intracranial arteries.
• Assessment of patterns and extent of collateral circulation in patients with known regions of severe stenosis or occlusion.
• Intraoperative monitoring during carotid surgery.
• Evaluation and follow-up of patients with vasoconstriction or spasm resulting from an illness, disease or injury, especially after subarachnoid hemorrhage.
• Detection of arteriovenous (AV) malformations and studying their supply arteries and flow patterns.
• An adjunct in the assessment of patients with suspected brain death.

• Migraine or headaches.
• Dizziness not associated with localizing symptoms.
• Evaluation of patients with dilated vasculopathies, such as fusiform aneurysms.
• Assessing autoregulation, physiologic and pharmacological responses of cerebral arteries.
• Evaluating children with various vasculopathies, such as sickle cell disease, moya-moya and neurofibromatosis.
• Assessment of physiologic and pharmacologic responses of cerebral arteries.

• Evaluation of brain tumors.
• Assessment of familial and degenerative disease of the cerebrum, brainstem, cerebellum, basal ganglia and motor neurons.
• Evaluation of infectious and inflammatory conditions.
• Evaluation of psychiatric disorder.
• Evaluation of epilepsy.
• Routine evaluation of cerebrovascular symptoms and signs.

• Physician’s office and physician-directed clinic.
• Outpatient and inpatient hospital.
• Nursing facilities.
• Other facilities such as Independent Diagnostic Testing Facilities (IDTFs).

• Registered Vascular Specialist (RVS) provided by Cardiovascular Credentialing International (CCI).
• Registered Vascular Technologist (RVT) provided by the American Registry of Diagnostic Medical Sonographers (ARDMS).
• Vascular Sonographer (VS) provided by the American Registry of Radiologic Technologists, Sonography (ARRT) (S).

• American College of Radiology (ACR) Vascular Ultrasound Accreditation Program.
• Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).

• Safe and effective.
• Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
93875©	Extracranial study
93880©	Extracranial study – Fee schedule amount – $188.59
93882©	Extracranial study Fee schedule amount – $ 128.22
93886©	Intracranial study  Fee schedule amount – $185.49
93888©	Intracranial study Fee schedule amount – $145.71
93890©	Tcd, vasoreactivity study Fee schedule amount – $199.96
93892©	Tcd, emboli detect w/o inj
93893©	Tcd, emboli detect w/ inj

Follow-up examination, following other surgery

V72.81	Pre-operative cardiovascular examination
V72.83	Other specified pre-operative examination

• Stenosis of 20 percent to 50 percent (diameter reduction), annual study.
• Stenosis of 50 percent to 99 percent (every six months). Medicare expects that few patients with high-grade carotid stenosis (79-99 percent) will be followed medically with repeated diagnostic testing. Because surgery is usually indicated for stenosis of 80 percent to 99 percent, the medical record of patients followed medically with high-grade stenosis must unequivocally indicate medical necessity for repeated diagnostic testing.
• Medicare would not expect, after carotid endarterectomy, that repeat examinations occur more frequently than at six weeks, six months, 12 months and yearly, thereafter. Postoperatively, follow-up studies should be unilateral unless signs and symptoms or known contralateral stenosis provide indications for a bilateral procedure.