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Non-Invasive Vascular Study Documentation

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The subject of documentation for Non-Invasive Vascular Studies was recently included in an AMA/ACR Clinical Examples in Radiology article.[1] The article addressed the necessary documentation for two specific CPT codes:

  • 93965 – Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography)
  • 93970 – Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study

The AMA/ACR article states:

“At the very minimum, the technique part of the report should state ‘A duplex doppler study was performed’, ideally it should state, ‘A duplex Doppler study was performed consisting of integrated two-dimensional (2D) real-time imaging: color flow Doppler and Doppler spectral analysis utilizing 5.0 MHz and 7.0 MHz linear array probes.’ The body of the report should optimally describe that normal flow, compressibility, and augmentation were documented on Doppler spectral analysis.”

The article goes on to state, “Physiologic studies consist of functional measurement procedures, including ankle/brachial index measurement (ABI), blood pressure (BP) and physiologic waveforms, segmental pressure measurement, plethysmography, and stress testing”.

The AMA/ACR also indicates that “While it is not necessary to dictate in the report that permanent images have been obtained, radiologists are encouraged to note permanent image documentation within the report in case of an audit and an inability to locate the actual images”.

If you have any questions regarding this notification, please contact your SVA Healthcare Services professional.

[1] AMA/ACR Clinical Examples in Radiology, Vol 8, Issue 2, Spring 2012


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