S45.801A — Unspecified injury of other specified blood vessels at shoulder and upper arm level, right arm, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must contain relevant medical history, physical examination, and results of pertinent diagnostic tests that fully support the medical necessity of each non-invasive vascular study.
- Diagnostic tests must be ordered by the treating practitioner (or consulting physician) who will use the test results in managing the patient's specific medical problem; the ordering practitioner's name and NPI must be reported on the claim when required.
- Providers of interpretations and technical personnel must maintain documentation of training, licensure, certification, and proficiency for post-payment audit; IDTF supervising physicians must document proficiency in each diagnostic procedure performed.
- For diagnostic tests, report the test result if known; if not known, report the symptoms prompting the test on the claim.
Key Coverage Criteria
- Non-invasive vascular studies (duplex scan, physiologic studies, plethysmography, transcranial Doppler) are covered when ordered by the treating or consulting practitioner and medically necessary to evaluate, diagnose, or manage vascular disease.
- Initial autogenous access vessel mapping should be billed with HCPCS codes 93985 or 93986 and is covered when medically necessary for surgical planning.
- Subsequent autogenous access mapping may be billed with CPT codes 93970 or 93971 when clinically indicated.
- Pre-surgical radial artery conduit mapping may be performed and accompanied by vein-mapping when either study shows insufficient conduits for multiple bypass procedures.
- Immediate post-operative studies of an access or bypass site are covered if pulses are lost, become equivocal, or the patient develops signs or symptoms of ischemia suggesting need for repeat intervention.
- Non-invasive vascular studies are medically necessary when the ordering physician reasonably expects test outcomes will potentially impact clinical management and significant signs or symptoms of arterial or venous disease are present, and the test is not redundant of other required diagnostics.
3 Active Policies
A56758 — Billing and Coding: Non-Invasive Vascular Studies
J06
L33627 — Non-Invasive Vascular Studies
J06
ANTHEM-CG-MED-73 — CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
Related Codes
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