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September 15, 2011

Proper Billing for CPT® Codes 939701and 939712

Data analysis has revealed inappropriate use of CPT® code 939653 when billed with CPT® codes 93970 or 93971.

The clinical information obtained by the procedures defined by CPT® codes 93970 and 93971 is more advanced than the information provided by CPT® 93965. If adequate information cannot be determined by the services rendered with 93970 or 93971 then more advanced imaging may be necessary.

Effective 01 October 2011, when CPT® code 93965 is billed with CPT® 93970 or 93971 the billing of CPT® code 93965 will be considered not medically necessary and will be denied. In the rare, unexpected case where an exception should be made, this exception can be reconsidered on a case by case basis via the redetermination process.

Along with the redetermination request the provider shall submit for review the imaging results and the ordering physician's clinical notes that clearly demonstrating why CPT® 93965 is necessary in addition to 93970/93971, how this information will be used to treat the patient and that more advance imaging is not available to better provide clinical guidance in accordance with usual standard of care. The documentation shall also include a properly executed physician's order that states specifically what information is to be gained by CPT® 93965.

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1CPT 93970: Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

2CPT 93971:  unilateral or limited study

3CPT 93965: Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phyleborheography, impedance plethysmography)


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