Documenting Percentage of Stenosis

Whether you are documenting to meet PQRS Measure 195 requirements or are treating an arterial stenosis by PTA for medical necessity, it is the documentation of the percentage (%) of stenosis that counts. Terms such as “mild”, “moderate”, or “severe”, without the specified percentage (%) are not specific enough…

In various publications, CMS repeatedly requires documentation of the stenosis by percentage. This newsletter highlights just three specific areas where the stenosis has to be documented by percentage (%):  PQRS Measure 195, Local Coverage Determination (LCD) L34062 and National Coverage Determination (NCD) 20.7.

PHYSICIAN QUALITY REPORTING SYSTEM (PQRS)

PQRS is a reporting program that encourages individual eligible professionals (EPs) and group practices to report information on the quality of care they provide to their patients.  To avoid a negative payment adjustment, successfully report on the measures that are applicable to you.  Specifically, Measure 195 focuses on the requirement of stenosis measurement for carotid imaging studies (e.g., CTA, MRA, Duplex scans, and Carotid Angiography).

Measure 195 Radiology:  Stenosis Measurement in Carotid Imaging Reports

Measure description:  “Percentage of final reports for carotid imaging studies performed that include direct or indirect reference to measurements of distal internal carotid diameter as the denominator for stenosis measurement.”

Eligible Cases:

• 36222 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the cerviocerebral arch, when performed
• 70498 Computed tomographic angiography, neck with contrast material(s), including noncontrast images, if performed, and image postprocessing
• 70547 Magnetic resonance angiography, neck; without contrast material(s)
• 70548 with contrast material(s)
• 70549 without contrast material(s), followed by contrast material(s) and further sequences
• 93880 Duplex scan of extracranial arteries:  complete bilateral study
• 93882 unilateral or limited study

It is important to note that documenting the method used to obtain the measurements such as NASCET is important but without the percentage (%), it can’t be counted as successful reporting.  In the examples CMS provides for successful reporting, notice the percentage of stenosis is given in each case:

• “Severe left ICA stenosis of 70-80% by NASCET criteria” or
• “Severe left ICA stenosis of 70-80% by criteria similar to NASCET” or
• “70% stenosis derived by comparing the narrowest segment with the distal luminal diameter as related to the reported measure of the arterial narrowing” or
• “Severe stenosis of 70-80% – validated velocity measurements with angiographic measurements, velocity criteria are extrapolated from diameter data as defined by the Society of Radiologists in Ultrasound Consensus Conference Radiology 2003; 229;340-346.”

For this Measure, if the actual percentage (%) is not documented, a modifier is assigned (8P Performance Not Met) to indicate it wasn’t done.

• Question:  What if the study shows no evidence of carotid stenosis?
• Answer:  Document “Zero % stenosis.”

For successful PQRS reporting, always document the stenosis by percentage.

LOCAL COVERAGE DETERMINATIONS (LCDs) AND NATIONAL COVERAGE DETERMINATIONS (NCDs)

An NCD will identify whether Medicare will cover specific services, procedures, or technologies on a national basis.  But if an NCD does not specifically exclude/limit an indication or circumstance, or if the item or services is not mentioned at all in an NCD or in a Medicare manual, then an LCD may be in place to offer guidance.  LCDs are set by the local Medicare contractor.  Below are examples of an LCD and a NCD that identifies where a documentation of stenosis by percentage (%) is required:

LCD for Dialysis Access Maintenance – L34062

“PTA of the AV dialysis access and/or afferent and efferent vessels is not necessary for all poorly functioning AV dialysis accesses.  Coverage will be considered if there is documentation supporting the presence of residual, hemodynamically significant stenosis, generally >/50 percent of the vessel diameter.  There must be clear documentation of the site and extent of any hemodynamically significant stenosis.  This documentation may be subjected to medical necessity review.”

NCD for Percutaneous Transluminal Angioplasty (PTA) – 20.7

Medicare covers PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent with embolic protection for the following:

• Patients who are at high risk of CEA and who also have symptomatic carotid artery stenosis >70%.  Coverage is limited to procedures performed using FDA-approved carotid artery stenting (CAS) systems and FDA-approved or –cleared embolic protection devices.  If deployment of the embolic protection device is not technically possible, and not performed, then the procedure is not covered by Medicare.
• Patients who are high risk for CEA and have symptomatic carotid artery stenosis between 50% and 70%, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost under the clinical trials policy (Medicare National Coverage Determination (NCD) Manual 310.1), or in accordance with the NCD on (CAS) post-approval studies (Medicare NCD Manual 20.7)
• Patients who are at high risk for CEA and have asymptomatic carotid artery stenosis >80%, in accordance with the Category B IDE clinical trials regulation (42 CFR 405.201), as a routine cost under the clinical trials policy (Medicare NCD Manual 310.1), or in accordance with the NCD on CAS post- approval studies (Medicare NCD Manual 20.7).

Document the Percentage (%) of Stenosis for Every Vessel Treated

Example: From a left common femoral approach, the catheter was advanced into the aorta, both renal arteries were then selectively catheterized and imaged which revealed 80% stenosis in the left renal artery and 80% stenosis in the right renal artery. Angioplasty was then performed in each renal artery.

SUMMARY 

PQRS REPORTING

• Measure 195, diagnostic CTA, MRA of the neck, Duplex carotid imaging, and carotid angiography requires that you document the stenosis by percentage (%).
• Without the percentage of stenosis, mild, moderate, or severe stenosis does not count as successful reporting. Other documentation, such as “No evidence of stenosis,” “Unremarkable study,” or “No plaque identified”, also does not count as successful reporting.
• In the event the study shows no evidence of carotid stenosis, document “Zero % stenosis”.

LCD and NCD – ESTABLISHING MEDICAL NECESSITY FOR TREATMENT

• Always document the degree of stenosis by percentage (%)
• Document the degree of stenosis for every vessel treated
• Coders, auditors and payers are looking for the degree of stenosis by percentage

If you have a documentation issue that you would like to see covered, please contact Wendy Block, CPC, RCC, CIRCC at wblock@streamlinemd.comor by phone at 330.564.2618.