March 24, 2022

ACR NCCI/MUE Appeal Unsuccessful for Doppler Venous Ultrasounds

The American College of Radiology® (ACR®) sent an appeal letter in October 2021 disagreeing with the Centers for Medicare and Medicaid Services' (CMS) implementation of the National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) value of “1”, and requested that a correction be made to increase the MUE value to “2” for CPT® codes 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study and 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study.

An MUE value is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Any procedures performed in excess of the MUE value are automatically considered to be "medically unlikely" and the claims will be denied. However, unlike some NCCI edits, MUE edits may still be paid. If claim denials based on the edits are appealed, Medicare Administrative Contractors (MACs) may pay unit of service (UOS) in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units.

Our CPT® Advisors (physician volunteers representing multiple radiology societies) believe there are many clinical scenarios where it would be reasonable to perform a bilateral upper extremity deep vein thrombosis (DVT) exam on the same day as a bilateral lower extremity DVT exam, or a unilateral DVT exam of an arm on the same day as a unilateral DVT exam of a leg.

Our initial appeal letter was denied by NCCI, but we persisted and requested a “face-to-face” virtual meeting with Capitol Bridge, administrator of the NCCI edits and CMS.

During the 6 am PST virtual meeting, the CPT Advisors cited numerous examples when complete or limited duplex venous ultrasound examinations of both upper and lower extremities may be performed more than once per session or more than once on the same date of service, including:

a) Hypercoagulable blood condition (e.g., excessive blood clotting), such as polycythemia, which carries an increased risk of vascular thrombotic events.

b) Prolonged hospitalization and immobilization, which carries an increased risk of vascular thrombotic events; this is particularly important in patients who cannot be anticoagulated and have been immobile for a long period of time (e.g., post-surgical patients, patients undergoing treatment for hemorrhagic stroke).

c) Fever of unknown origin — for identification of the source of infection (which could be due to septic emboli).

d) Pulmonary emboli — for identification of the source of emboli.

e) Patent foramen ovale — for identification of blood clots in the extremities.

f) Generalized extremity swelling — determination of the etiology of the swelling.

g) Septic emboli and intravascular lines.

In these situations, a duplex ultrasound of all four extremities may be medically necessary and requested. Additionally, a topical and increasing cause of hyper-coagulability is COVID-19. Many patients with COVID-19 infection develop a coagulopathy resulting in thrombotic events involving multiple blood vessels. This is a major cause of mortality; it is important for treatment purposes to identify the location and extent of the thrombi.

The CPT Advisors also pointed out the current MUE value of “1” may lead to the performance of separate procedures on separate dates of service. This would not only be inconvenient for patients but may even place patient safety at risk. For these reasons, the ACR and other radiology societies strongly advocated for an MUE unit of “2” so that both upper and lower extremities examinations can be reported during the same session or on the same day, when performed.

Despite the multiple efforts made by the CPT Advisors, CMS retained the current MUE value of “1” for codes 93970 and 93971. Per CMS, "this decision is consistent with CMS’ MUE policy and criteria as documented in the NCCI Policy Manual."

Our dedicated team of ACR Economics Commission staff and volunteer physicians do succeed on a significant number of appeals and, more importantly, succeed a significant percentage of the time in preventing misguided proposed edits from even being enacted. Unfortunately, due to confidentiality rules within NCCI, we are not allowed to publish those “wins” when proposed edits are not enacted.

For more information on MUEs see Medlearn or contact Maria Tran, ACR Director, Economic Policy.