Cardiology Coding Alert

What You Need to Know to Get Your ABI Billing Right

We'll tell you how to report handheld Doppler services

When your cardiologist uses a handheld Doppler to measure a patient's ankle/brachial index (ABI), report an E/M office visit code rather than 93922 or 93923 for the service, or you'll risk payer scrutiny for overbilling. Physicians use hand-held Dopplers, such as the Elite and Pocket-Dop II, to detect blood flow in the arms and legs and to detect differences in arm and leg pressure that could indicate arterial atherosclerosis.

Typically, the blood pressures in the arm and the leg are the same, and in these circumstances the ABI will be close to 1.0. When there is arterial disease in the leg, for instance, the blood pressure may be lower in the leg than in the arm, and the ABI will be less than 1.0.
Usually, physicians use handheld Dopplers when patients have diminished or absent pulses or to check hard-to-find peripheral vessels in the office, says Nancy Reading, RN, BS, CPC, president-elect of the American Academy of Professional Coders (AAPC) and staff educator with University Medical Billing at the University of Utah in Draper.

"We're using them more and more for screening purposes," says Rebecca Sanzone, CPC, billing manager for Midatlantic Cardiovascular Associates of Baltimore. "If the ABIs are low or abnormal, the physician schedules a peripheral vascular consult for the patient."

No Flow Analysis, No Ultrasound Code

Although these devices generate some useful data, "handheld Doppler information isn't very detailed and does not generate a print out analyzing the results," says Sandy Fuller, CPC, cardiology coding specialist and compliance officer for a cardiology practice in Tyler, Texas.
So you can't report 93922 (Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral [e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement]) for a single-level waveform analysis or 93923 (... multiple levels or with provocative functional maneuvers, complete bilateral study [e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements ...]) for segmental studies, according to CPT's non-invasive vascular study guidelines.
When the physician uses a handheld or pocket Doppler device, the service is part of the E/M physical exam, so you would not report this separately, Reading and Sanzone say. "Even if you perform segmental pressures up and down both lower extremities and remark how biphasic, triphasic or monophasic the arteries are and spend a lot of time doing so, the service is part of the physical exam," says Eric Gardner, MD, with the Vascular Surgery Center in Pinehurst, N.C., who notes that he uses these devices in most of his patient visits.
"You must have hard-copy results that indicate Doppler and/or plethysmographic waveforms to bill 93922 or 93923," Gardner says. For these results, you'll need to use special segmental arterial Doppler machines. Billing these codes for handheld Doppler readings would be fraudulent, he says.
Medicare payers have issued statements confirming this position. For instance, CIGNA Healthcare, carrier for Idaho, North Carolina and Tennessee, indicates in a recent bulletin that handheld Doppler studies are part of the physical exam, so you should not report diagnostic ultrasound codes (93875-93990) for these services.
But if the handheld device provides the same data as the traditional Doppler, and the provider documents this data in the report, you can bill for this service, CIGNA states.
You might be able to justify a higher-level E/M code for handheld Doppler services, but don't count on it. You can document the Doppler use as part of the cardiovascular system exam, but keep in mind that pulse documentation from a Doppler may not be enough to justify a higher-level code, Gardner says. The ABI alone would not take the service level higher, Sanzone says.
"Usually, I can meet the criteria for a level-three exam by reporting a 'detailed' examination of the distal pulses," Gardner says. "If I feel the need to examine these vessels closely, I will have examined other organ systems in a similarly complete manner, and in doing so, will have met the documentation requirements for more complete exams."