Reimbursement guidelines for follow-up cerebrovascular arterial studies

Q.

I am inquiring whether you know if there is a rule by Medicare or other insurance companies that a patient must wait until after 365 days have passed since having an ultrasound carotid exam—CPT code 93880—to have another carotid ultrasound performed? I am in Illinois.

A.

If you are asking about a screening carotid ultrasound, then that is not covered at all by Medicare. Other payors may, but you would have to check each patient’s insurance plan.

If you are asking about diagnostic exams, for Medicare in Illinois you have an LCD and Billing and Coding Article. The coding article includes the following:

Utilization Guidelines:

Frequency of follow-up studies will be carefully monitored for medical necessity and it is the responsibility of the physician/provider to maintain documentation of medical necessity in the patient’s medical record. Guidelines for follow-up cerebrovascular arterial studies include:

• Stenosis of 20-49% (diameter reduction), an annual study;
• Stenosis of 50-79%, every six months;
• Stenosis of 80-99%, every 6 months if surgery not performed; and
• After carotid endarterectomy, repeat ipsilateral/unilateral examinations are allowable at six weeks, six months, and one year. During the first year, follow-up studies should be on the ipsilateral side unless signs and symptoms or previously identified disease in the contralateral carotid artery provide indications for a bilateral procedure.