Wednesday, December 30, 2015

Diagnostic Abdominal Aortography and Renal Angiography-Local Coverage Determination

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity
1. The indications for renal arteriography adapted from the American College of Radiology (1999) include the following:

Severe and/or difficult to control renal vascular hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

Recent onset of severe or relatively severe hypertension (systolic blood pressure greater than or equal to 160 mmHg or diastolic blood pressure greater than or equal to 100 mmHg);

Sudden need to increase medications to control hypertension (uncontrolled hypertension with a systolic blood pressure greater than or equal to 160 mmHg or a diastolic blood pressure greater than or equal to 100 mmHg on at least two anti-hypertensive drugs);

Deterioration of renal function; and

Abnormal radionuclide renogram.

2. Renal arteriography is indicated for those patients with recurrent acute pulmonary edema who are status post-op renal transplantation or patients with recurrent (flash) pulmonary edema.

3. Renal arteriography is indicated for those patients having primary or secondary, benign or malignant neoplasm of the kidney.

4. Abdominal aortography and/or renal arteriography may be indicated for those patients with known/suspected aneurysm, dissection, or trauma involving the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

5. Abdominal aortography and/or renal arteriography may be indicated for those patients having mid-abdominal bruits or known/suspected vascular diseases of the abdominal aorta, the renal arteries, other visceral arteries, and/or the iliac arteries.

6. In addition to the initial procedure, an appropriate frequency of repeat procedures can be allowed as long as medical necessity is clearly
established and documented, e.g., there is a reason for performing the procedure. It is expected that important diagnostic information will be obtained from the angiography, which will assist in the patient’s management and treatment. Repeat angiography can be acceptable if there is an appearance of new and incapacitating symptoms or an exacerbation or chronic symptoms, even following an interventional procedure, such as PTA and/or renal stenting.

Diagnostic angiography performed at the time of an interventional procedure is separately reportable if:

a. No prior catheter-based angiographic study is available and a full diagnostic study is performed, and the decision to intervene is based on the diagnostic study, or

b. A prior study is available, but as documented in the medical record:

The patient’s condition with respect to the clinical indication has changed since the prior study; OR

There is inadequate visualization of the anatomy and/or pathology; OR

There is a clinical change during the procedure that requires new evaluation outside the target area of intervention

7. Appropriate non-invasive tests should be performed prior to the repeat angiography. A trial of or a change in medical management would be expected prior to repeat angiography unless the patient has not responded to an adequate trial of medical management or is deemed unstable and in need of some type of surgical intervention. In all instances, documentation must be submitted upon request justifying the repeat procedure and establishing medical necessity.

8. These services may be performed in a hospital, a hospital outpatient area, or an approved independent catheterization laboratory.

9. Aortography (from ACR Guideline: Quality Improvement Guidelines for Diagnostic Arteriography, September 2003):

Intrinsic abnormalities, including transection, dissection, aneurysm, occlusive disease, aortitis, and congenital anomaly;

Evaluation of aorta and its branches prior to selective catheterization and performance of therapeutic interventional procedures; or

Before interventional procedures.

10. Renal Arteriography (from ACR guideline: Practice Guideline for the Performance of Diagnostic Arteriography in Adults, Res. 25, Amended 2004):

Renovascular occlusive disease (e.g., for hypertension or progressive
renal insufficiency);

Renal vascular trauma;

Primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis;

Renal tumors;

Hematuria of unknown cause (following inconclusive noninvasive testing [not included in ACR]);

Pre- and postoperative evaluation for renal transplantation; or

Evaluation prior to performance of therapeutic interventional procedures.



CMS issued HCPCS code G0278 for femoral and/or iliac angiography when done at the time of coronary angiography. Medicare would not expect to see a high percentage of femoral and/or iliac angiography done at the same time of coronary studies and such billing could be subject to review.

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