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.”
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:
For this Measure, if the actual percentage (%) is not documented, a modifier is assigned (8P Performance Not Met) to indicate it wasn’t done.
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:
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.
LCD and NCD – ESTABLISHING MEDICAL NECESSITY FOR TREATMENT
If you have a documentation issue that you would like to see covered, please contact Wendy Block, CPC, RCC, CIRCC at firstname.lastname@example.org or by phone at 330.564.2618.