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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-93875-17

Original Effective Date: 07/15/01

Reviewed: 01/23/12

Revised: 10/01/16

Subject: Transcranial Doppler Studies

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Transcranial Doppler ultrasound (TCD) is a non-invasive ultrasound technology for imaging blood flow in the cerebral arteries and veins. In TCD, ultrasonic waves are generated by a probe placed over the skull generates ultrasonic waves. The bony plate of the skull limits TCD measurements to three primary sites (or acoustic windows), which are the temporal bone along the orbito-meatal line, the foramen magnum at the base of the skull, and the optic foramina. Sound waves transmitted through these windows are reflected by blood cells in the intracranial vasculature. The frequency shifts of the reflected sound waves recorded at the probe are used in evaluating direction, depth, speed, and characteristics of blood flow in the intracranial arteries.

POSITION STATEMENT:

Transcranial Doppler studies meet the definition of medical necessity when performed for ANY of the following conditions:

Transcranial Doppler studies are considered experimental or investigational, as there is insufficient clinical evidence to support the use of transcranial Doppler studies for all other indications, and specifically for the following conditions:

There are ongoing clinical studies on the use of transcranial Doppler studies for all other indications, the evidence is insufficient to permit conclusions on net health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe transcranial Doppler studies:

CPT Coding:

93886

Transcranial Doppler study of the intracranial arteries; complete study

93888

Transcranial Doppler study of the intracranial arteries; limited study

93890

Transcranial Doppler study of the intracranial arteries; vasoreactivity study

93892

Transcranial Doppler study of the intracranial arteries; emboli detection without intravenous microbubble injection

93893

Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

D57.00 – D57.02

Hb-SS disease with crisis

D57.1

Sickle-cell disease without crisis

D57.20

Sickle-cell/Hb-C disease without crisis

D57.211 – D57.219

Sickle-cell/Hb-C disease with crisis

D57.80

Other sickle-cell disorders without crisis

D57.811 – D57.819

Other sickle-cell disorders with crisis

G45.0

Vertebro-basilar artery syndrome

G93.9

Disorder of brain, unspecified

G93.81– G93.89

Other specified disorders of brain

I60.00 – I60.02

Nontraumatic subarachnoid hemorrhage from carotid siphon and bifurcation

I60.10 – I60.12

Nontraumatic subarachnoid hemorrhage from middle cerebral artery

I60.2

Nontraumatic subarachnoid hemorrhage from anterior communicating artery

I60.30 – I60.32

Nontraumatic subarachnoid hemorrhage from posterior communicating artery

I60.4

Nontraumatic subarachnoid hemorrhage from basilar artery

I60.50 – I60.52

Nontraumatic subarachnoid hemorrhage from vertebral artery

I60.6

Nontraumatic subarachnoid hemorrhage from other intracranial arteries

I60.7

Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery

I60.8

Other nontraumatic subarachnoid hemorrhage

I60.9

Nontraumatic subarachnoid hemorrhage, unspecified

163.011 – I63.019

Cerebral infarction due to thrombosis of vertebral artery

I63.02

Cerebral infarction due to thrombosis of basilar artery

I63.031 – I63.039

Cerebral infarction due to thrombosis of carotid artery

I63.09

Cerebral infarction due to thrombosis of other precerebral artery

I63.10

Cerebral infarction due to embolism of unspecified precerebral artery

I63.111 – I63.119

Cerebral infarction due to embolism of vertebral artery

I63.12

Cerebral infarction due to embolism of basilar artery

I63.131 – I63.139

Cerebral infarction due to embolism of carotid artery

I63.211 – I63.219

Cerebral infarction due to unspecified occlusion or stenosis of unspecified vertebral arteries

I63.22

Cerebral infarction due to unspecified occlusion or stenosis of basilar arteries

I63.231 – I63.239

Cerebral infarction due to unspecified occlusion or stenosis of unspecified carotid arteries

I63.30

Cerebral infarction due to thrombosis of unspecified cerebral artery

I63.311 – I63.319

Cerebral infarction due to thrombosis of middle cerebral artery

I63.321 – I63.329

Cerebral infarction due to thrombosis of anterior cerebral artery

I63.331 – I63.339

Cerebral infarction due to thrombosis of posterior cerebral artery

I63.341 – I63.349

Cerebral infarction due to thrombosis of cerebellar artery

I63.39

Cerebral infarction due to thrombosis of other cerebral artery

I63.40

Cerebral infarction due to embolism of unspecified cerebral artery

I63.50

Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery

I63.59

Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery

I63.411 – I63.419

Cerebral infarction due to embolism of middle cerebral artery

I63.421 – I63.429

Cerebral infarction due to embolism of anterior cerebral artery

I63.431 – I63.439

Cerebral infarction due to embolism of posterior cerebral artery

I63.441 – I63.449

Cerebral infarction due to embolism of cerebellar artery

I63.49

Cerebral infarction due to embolism of other cerebral artery

I63.511 – I63.519

Cerebral infarction due to unspecified occlusion or stenosis of middle cerebral artery

I63.521 – I63.529

Cerebral infarction due to unspecified occlusion or stenosis of anterior cerebral artery

I63.531 – I63.539

Cerebral infarction due to unspecified occlusion or stenosis of posterior cerebral artery

I63.541 – I63.549

Cerebral infarction due to unspecified occlusion or stenosis of cerebellar artery

I63.59

Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery

I63.6

Cerebral infarction due to cerebral venous thrombosis, nonpyogenic

I63.8

Other cerebral infarction

I63.9

Occlusion and stenosis of unspecified precerebral artery

I65.01 – I65.09

Occlusion and stenosis of vertebral artery

I65.1

Occlusion and stenosis of basilar artery

I65.21 – I65.29

Occlusion and stenosis of carotid artery

I65.8

Occlusion and stenosis of other precerebral arteries

I65.9

Occlusion and stenosis of unspecified precerebral artery

I66.01 – I66.09

Occlusion and stenosis of middle cerebral artery

I66.11 – I66.19

Occlusion and stenosis of anterior cerebral artery

I66.21 – I66.29

Occlusion and stenosis of posterior cerebral artery

I66.3

Occlusion and stenosis of cerebellar arteries

I66.8

Occlusion and stenosis of other cerebral arteries

I67.2

Cerebral atherosclerosis

P05.00 – P05.08

Newborn light for gestational age

P05.10 – P05.18

Newborn small for gestational age

P07.00 – P07.03

Extremely low birth weight newborn

P07.10 – P07.18

Other low birth weight newborn

P07.20 – P07.25

Extreme immaturity of newborn

P07.30

Preterm newborn, unspecified weeks of gestation

P07.31

Preterm newborn, gestational age 29 completed weeks

P07.33

Preterm newborn, gestational age 30 completed weeks

Q28.2

Arteriovenous malformation of cerebral vessels

Q28.3

Other malformations of cerebral vessels

REIMBURSEMENT INFORMATION:

The procedure codes for transcranial Doppler studies include the following services:

NOTE: According to CPT, the use of simple hand-held or other Doppler device that does not produce a hard copy report or a report that does not permit analysis of the bi-directional vascular flow, is considered to be part of the physical examination of the vascular system and is not separately reported or reimbursed as 93886 or 93888.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Transcranial Doppler Studies, (L29293) located at fcso.com.

DEFINITIONS:

Arterial-venous malformation (AVM): abnormal connection between an artery and a vein.

Carotid endarterectomy: surgical procedure used in the treatment of atherosclerosis that involves opening the carotid artery of the neck to remove plaque deposits.

Embolism: sudden blockage of an artery by a clot or foreign material, which has been brought to the site by the blood stream.

Transcranial: blood vessels of the head are difficult to visualize through the cranial bone (skull), but can be viewed through certain areas such as the eye sockets, the temple, and the base of the skull, where a sound wave probe can visualize cerebral or intracranial blood vessels.

RELATED GUIDELINES:

None applicable.

OTHER:

Other indexing terms:

Transcranial Doppler ultrasound
TCD

REFERENCES:

  1. American College of Radiology (ACR) Practice Guideline for the Performance of Transcranial Doppler Ultrasound for Adults and Children. Effective 10/01/07.
  2. Blue Cross Blue Shield Association Medical Policy Reference Manual. 6.01.07 Transcranial Doppler Ultrasound, 06/12/08.
  3. Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-3. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.14, Plethysmography.
  4. Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-3. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.17, Noninvasive Tests of Carotid Function.
  5. Centers for Medicare & Medicaid Services (CMS) Manual System, Pub. 100-3. Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.5, Ultrasound Diagnostic Procedures.
  6. Florida Medicare Part B Local Coverage Determination. L6641 93886 Transcranial Doppler Studies 09/27/05.
  7. Ment LR, Bada HS, Barnes P, Grant PE, Hirtz D, Papile LA, Pinto-Martin J, Rivkin M, Slovis TL. Practice parameter: neuroimaging of the neonate: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002 Jun 25; 58(12): 1726-38.
  8. Sloan MA, Alexandrov AV, Tegeler CH, Spencer MP, Caplan LR, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Babikian VL, Lefkowitz D, Goldman RS, Armon C, Hsu CY, Gooding DS. Assessment: Transcranial Doppler ultrasonography: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004 May 11; 62(9): 1468-81.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/26/12.

GUIDELINE UPDATE INFORMATION:

07/15/01

Medical Coverage Guideline Reformatted and Revised.

12/15/02

Review and revision of guideline; ICD-9 diagnosis code corrected; references updated.

12/15/03

Review and revision of guideline consisting of updated references.

12/15/04

Review and revision of guideline consisting of updated references.

01/01/05

Annual HCPCS update; consisting of addition of 93890, 93892 and 93893.

02/15/06

Review and revision of guideline consisting of updated references.

02/15/07

Review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline.

02/15/08

Review and revision of guideline consisting of updated references.

02/15/10

Review and revision of guideline consisting of updated references.

01/15/11

Revision; related ICD-10 codes added.

12/01/11

Update; added related ICD-10 codes.

02/15/12

Scheduled review. Revised description section for clarification of technology. No change in position statements.

04/01/12

Update; added related ICD-10 codes.

01/01/14

Revision; Program Exceptions section updated.

10/01/15

Revision; updated ICD9 and ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Quarterly code update; deleted I60.20-I60.22; added I60.2.

Date Printed: August 18, 2017: 08:00 PM