Local Coverage Determination (LCD)

Transcranial Doppler Studies

L33977

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Document Note

Posted: 11/14/2019
Note: In the “Explanation of Revision:” in Revision History Number R4 it was indicated that the addition of ICD-10-CM codes was based on a reconsideration request in error. This addition of the ICD-10-CM codes was based on an external correspondence.

Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

LCD Information

Document Information

LCD ID
L33977

LCD Title
Transcranial Doppler Studies

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 10/29/2019

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Transcranial Doppler Studies. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Transcranial Doppler Studies and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published

Internet Only Manual (IOM) Citations:

CMS IOM Publication 100-08, Medicare Program Integrity Manual,

Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
- Chapter 1, Part 1, Section 20.14 Plethysmography, Section 20.17 Noninvasive Tests of Carotid Function
- Chapter 1, Part 4, Section 220.5 Ultrasound Diagnostic Procedures

Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

History/Background and/or General Information

Transcranial doppler uses low-frequency doppler transducers applied across the thin portions of the temporal bone (the temporal acoustic windows) to obtain flow velocity information from the basal intracerebral arteries. The transtemporal acoustic window provides access to hemodynamic data from the middle, anterior, and posterior cerebral arteries. A suboccipital approach, with insonation through the foramen magnum, provides access to the intracranial vertebral and basilar arteries, while a transorbital approach can be used to insonate the ophthalmic artery and the carotid siphon via the optic foramen. This data allows evaluation of the direction, depth, speed, and characteristics of flow in these vessels.

Covered Indications

Transcranial doppler evaluation of the intracranial cerebrovascular system will be considered medically necessary in any of the following circumstances:

The patient has suspected severe intracranial arterial stenosis based on finite clinical evidence of focal ischemia, and knowledge of this stenosis is necessary in order to properly care for the patient.
The patient has areas of known severe stenosis or occlusion of arteries supplying the brain and assessment of the pattern and extent of collateral circulation is necessary in order to properly care for the patient.
The patient has suffered a subarachnoid hemorrhage and transcranial doppler studies are necessary to assess vasoconstriction of cerebral vessels.
The patient has suspected or confirmed arteriovenous malformation, and an assessment of the arterial supply and flow pattern is necessary.
The patient has suspected brain death.

Limitations

Headaches or dizziness are not indications for transcranial doppler studies of the intracranial vessels unless associated with other localizing signs and symptoms such as nystagmus, limb ataxia, etc.

Transcranial doppler studies performed to monitor cerebral vascular resistance and the effects of vasodilators and other drugs in the treatment of stroke and other brain damage is considered investigational, and therefore not covered.

The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered part of the physical examination of the vascular system and is not separately reported. The appropriate assignment of a specific ultrasound CPT code is not solely determined by the weight, size, or portability of the equipment, but rather by the extent, quality, and documentation of the procedure. If an examination is performed with hand-carried equipment, the quality of the exam, printout, and report must be in keeping with accepted national standards.

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Requestor Name	Requestor Letter
	View Letter

Requestor Information

Contact for Comments on Proposed LCD

Coding Information

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Transcranial Doppler Studies (A57633) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Transcranial Doppler Studies (A57633) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options, Inc. reference LCD number – L29481

Bibliography

Sloan, M.A., Alexandrov, A.V., Tegeler, C.H., Spencer, M.P., Caplan, L.R., Feldman, E., et al. (2004). Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of The American Academy of Neurology. Retrieved September 13, 2005.

Society of Vascular Ultrasound-Professional performance guidelines. (2003). Transcranial Doppler (Non-Imaging). Retrieved September 13, 2005.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
10/29/2019	R4	Revision Number: 3 Publication: October 2019 Connection LCR B2019-020 Explanation of Revision: Based on CR 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes”, “Revenue Codes”, “CPT/HCPCS Codes”, “ICD-10 Codes that Support Medical Necessity”, “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018. Also, the following unspecified ICD-10-CM diagnosis codes were removed as it is the provider’s responsibility to code to the highest level of specificity: I60.00, I60.10, I60.30, I60.50, I60.7, I63.019, I63.039, I63.119, I63.139, I63.219, I63.239, I63.30, I63.319, I63.329, I63.339, I63.349, I63.40, I63.419, I63.429, I63.439, I63.449, I63.50, I63.519, I63.529, I63.539, I63.549, I65.09, I65.29, I66.09, I66.19, I66.29, I66.9. The effective date of this revision is for dates of service on or after October 29, 2019. In addition, based on a reconsideration request, the following ICD-10-CM codes were added to the “Group 1 Codes” “ICD-10 codes that are covered” section of the newly created billing and coding article: G45.2, G45.3, G45.4, G45.8, G45.9, G46.0, G46.1, G46.2, G97.31, G97.32, G97.48, G97.49, G97.51, G97.52, I61.0, I61.1, I61.3, I61.4, I61.5, I61.6, I61.8, I63.09, I63.19, I63.29, I67.1, I67.2, I67.7, I67.81, I67.82, I67.841, I67.848, I67.89, I67.9, I72.6, I74.9, I76, S09.0XXA, S09.0XXD, S09.0XXS, S15.111A, S15.111D, S15.111S, S15.112A, S15.112D, S15.112S, S15.121A, S15.121D, S15.121S, S15.122A, S15.122D, S15.122S, S15.191A, S15.191D, S15.191S, S15.192A, S15.192D, S15.192S, Z09. The effective date of this revision is for dates of service on or after October 29, 2019. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.	Reconsideration Request Other (Revisions based on CR 10901)
10/01/2018	R3	Revision Number: 2 Publication: September 2018 Connection LCR B2018-017 Explanation of Revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised. Descriptor revised for ICD-10-CM diagnosis code I63.239. In addition, the LCD was revised to indicate that diagnosis codes were added, deleted, and descriptors revised within existing diagnosis code ranges. The effective date of this revision is based on date of service. 10/01/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
10/01/2017	R2	Revision Number: 1 Publication: September 2017 Connection LCR B2017-011 Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Descriptor revised for ICD-10-CM diagnosis code I63.211. The effective date of this revision is based on date of service. 10/01/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.	Revisions Due To ICD-10-CM Code Changes
10/01/2016	R1	Based on CR 9677 (Annual 2017 ICD-10-CM Update), the LCD was revised; he following ICD-10 codes were added to these code ranges in the ICD-10 Codes that Support Medical Necessity field: I60.2 was added to code range I60.00 - I60.9 in Group 1 I63.013 was added to code range I63.011 - I63.039 in Group 1 I63.033 was added to code range I63.011 - I63.039 in Group 1 I63.113 was added to code range I63.111 - I63.139 in Group 1 I63.133 was added to code range I63.111 - I63.139 in Group 1 I63.213 was added to code range I63.211 - I63.239 in Group 1 I63.233 was added to code range I63.211 - I63.239 in Group 1 I63.313 was added to code range I63.30 - I65.8 in Group 1 I63.323 was added to code range I63.30 - I65.8 in Group 1 I63.333 was added to code range I63.30 - I65.8 in Group 1 I63.343 was added to code range I63.30 - I65.8 in Group 1 I63.413 was added to code range I63.30 - I65.8 in Group 1 I63.423 was added to code range I63.30 - I65.8 in Group 1 I63.433 was added to code range I63.30 - I65.8 in Group 1 I63.443 was added to code range I63.30 - I65.8 in Group 1 I63.513 was added to code range I63.30 - I65.8 in Group 1 I63.523 was added to code range I63.30 - I65.8 in Group 1 I63.533 was added to code range I63.30 - I65.8 in Group 1 I63.543 was added to code range I63.30 - I65.8 in Group 1	Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A57633 - Billing and Coding: Transcranial Doppler Studies
A57493 - Transcranial doppler studies revision to the Part B LCD (MCD Archive Site)

Updated On	Effective Dates	Status
10/25/2019	10/29/2019 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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Transcranial Doppler Studies

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Additional ICD-10 Information

General Information

Revision History Information

Associated Documents

Keywords

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