S85.109A — Unspecified injury of unspecified tibial artery, unspecified leg, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- All documentation must be maintained in the patient's medical record, legible, include patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- The medical record must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient's care.
- The submitted medical record must support the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- The ordering/referring physician/nonphysician practitioner must state the reason for the duplex scan in the order and provide relevant diagnostic information to the performing provider.
Key Coverage Criteria
- Duplex scan of lower extremity arteries is covered when medically necessary per LCD L33667, with the ordering/referring provider documenting signs and symptoms, relevant history (including known diagnoses and/or prior imaging) supporting evaluation of lower extremity arterial disease.
- Duplex scan is indicated for sudden pallor, numbness, and coolness of an extremity when vascular obstruction (embolism or thrombosis) is suspected.
- Duplex scanning of lower extremity arteries is medically necessary to establish the level and/or degree of arterial occlusive disease when significant signs and/or symptoms indicate a high likelihood of limb ischemia and the patient is a candidate for invasive therapeutic procedures.
- Duplex scan is indicated when physical exam shows absence or marked diminution of pulses in one or both lower extremities with symptoms of peripheral vascular ischemia and obstruction of lower extremity arteries is suspected.
- Duplex scan is indicated for claudication of less than one block or claudication of such severity that it significantly interferes with the patient's occupation or lifestyle.
- Duplex scan is indicated for suspected or known aneurysm or arteriovenous malformation of a lower extremity artery.
2 Active Policies
A57064 — Billing and Coding: Duplex Scan of Lower Extremity Arteries
J09
L33667 — Duplex Scan Of Lower Extremity Arteries
J09
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