01-145 Select Carotid Artery Screening Findings of Medical Review

Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B carotid artery screening billed on dates of service from January 1, 2023 through May 31, 2025. Below are the review results:

Project ID Project Title Error Rate No Response to ADR Denials
01-145 Select Carotid Artery Screening 32% 9%

Background

The Carotid arteries are major vessels that extend from the aorta up through the neck on either side. Both the right and left carotid arteries divide into two branches in the neck, known as the internal and external carotid arteries. The internal carotid supplies the brain with oxygenated blood while the external carotid artery further divides into seven branches that supply blood to the face and neck. These arteries carry oxygenated blood from the heart to the brain, and the development of atherosclerotic disease can impair blood flow leading to ischemic events. The development of signs, carotid bruit, or symptoms would warrant additional investigation of the carotid arteries with ultrasonography. These conditions include atherosclerosis leading to stenosis, carotid artery aneurysm, transient ischemic attack (TIA), and stroke.

Conditions can be identified by providers through neck examinations using a stethoscope to assess for sounds of blood flow disturbance, also known as a bruit, which results from the narrowing of the carotid artery and development of turbulent flow. Some individuals are unaware of issues involving the carotid arteries, as symptoms often lack severity or are absent entirely. Instead, the first sign of disease for most is a TIA or stroke.

Cerebrovascular arterial study testing methods include real-time duplex scans; and doppler ultrasound waveform with spectral analysis. Providers may perform diagnostic testing to determine the presence of arterial disease.

Medicare Part B covers carotid artery testing in certain circumstances for select indications. Non-invasive vascular studies done for screening purposes without signs or symptoms of disease, are considered not reasonable and necessary and are therefore non-covered by Medicare.

Inappropriate carotid artery screening/testing has been an ongoing area of focus for the Office of the Inspector General (OIG) and its work. The SMRC did complete data analysis and medical record reviews in June 2021 and again in April 2023, on claims billed with CPT code 93880 “duplex scan of extracranial arteries; complete bilateral study”. The SMRC identified overall claim error rates of 52% and 57%.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record review activities on claims billed with CPT code 93880 for date of service January 1, 2023 through May 31, 2025. The SMRC performed medical record review on supporting documentation, to determine if select Part B claims for carotid artery screening were reasonable and necessary.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

  • Overutilization
    • The documentation provided does not support the medical necessity for this number of services or items within this timeframe. Refer to SSA 1862, IOM, 100-08, MPIM Chapter 3, Section 3.6.2.2. This was appended when the carotid ultrasound was completed more frequently than the Local Coverage Determination (LCD)/Local Coverage Article (LCA) allowed.
  • Diagnosis Code
    • The documentation does not support the diagnosis code billed. Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3.” This was appended when the submitted documentation did not support findings or signs and/or symptoms related to the diagnosis code billed on the claim as indicated in the Local Coverage Article (LCA), A52992 Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies.
  • Medical Necessity
    • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination. Refer to Social Security Act 1862, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. This was appended when documentation did not support the percentage of bilateral carotid stenosis for the carotid ultrasound being performed or a covered indicaton was not met as outlined in the coverage requirements.

References

Social Security Act (SSA), Title XI

  • Section (§)1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

  • §1815(a) Payment to Providers of Services
  • §1833(e) Payment of Benefits
  • §1834(m)(4)(F) Special Payment Rules for Particular Items and Services
  • §1842(p)(4) Provisions Relating to the Administration of Part B
  • §1861(ddd)(1) Additional Preventive Services; Preventive Services
  • §1861(s)(2)(K) Miscellaneous Provisions (Definitions of Services, Institutions, etc.)
  • §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
  • §1869(f)(1)(B) Determinations; Appeals
  • §1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • §1893(f)(7)(A)(B) (i-iv),(h)(4)(B) Medicare Integrity Program

Title 42 Code of Federal Regulations (CFR)

  • §410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
  • §410.33 Independent Diagnostic Testing Facility
  • §410.64 Additional Preventative Services
  • §411.15(k)(1) Particular Services Excluded From Coverage
  • §424.5(a) Basic Conditions

Public Law

Federal Register

  • Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov) external link icon

Internet Only Manuals (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub.) 100-03

  • Chapter (Ch). 1, Part 1, §20.17 Noninvasive Tests of Carotid Function

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

  • Ch. 6, §20.4 Outpatient Diagnostic Services
  • Ch. 15, §80.6.1-80.6.4 Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests
  • Ch. 16, §20 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

  • Ch.13, §10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
  • Ch. 13, §20 Payment Conditions for Radiology Services
  • Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
  • Ch. 30, §50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • Ch. 35, Independent Diagnostic Testing Facility (IDTF)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

  • Ch. 3, §3.2.3.2 Time Frames for Submission
  • Ch. 3, §3.2.3.3 Third-party Additional Documentation Request
  • Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
  • Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
  • Ch. 3, §3.3.2.1 Documents on which to Base a Determination
  • Ch. 3, §3.3.2.4 Signature Requirements
  • Ch. 3, §3.6.2.2 Reasonable and Necessary Criteria
  • Ch. 3, §3.6.2.4 Coding Determinations
  • Ch. 10, §10.2.2.4 Independent Diagnostic Testing Facility (IDTFs)
  • Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

  • NCCI Policy Manual for Medicare Services, Effective January 1, 2023-December 31, 2025. Chapter 11, Section I. Cardiovascular Services

Local Coverage Determination (LCD)

  • L33627 Non-Invasive Vascular Studies
  • L33695 Non-Invasive Extracranial Arterial Studies
  • L33910 Independent Diagnostic Testing Facility (IDTF)
  • L34045 Non-Invasive Vascular Studies
  • L35397 Non-Invasive Cerebrovascular Arterial Studies
  • L35448 Independent Diagnostic Testing Facility (IDTF)
  • L35753 Non-Invasive Cerebrovascular Studies

Local Coverage Article (LCA)

  • A52992 Non-Invasive Cerebrovascular Arterial Studies
  • A53252 Independent Diagnostic Testing Facility (IDTF)
  • A56697 Non-Invasive Vascular Studies
  • A56758 Non-Invasive Vascular Studies
  • A57592 Non-Invasive Cerebrovascular Studies
  • A57670 Non-Invasive Extracranial Arterial Studies
  • A57807 Independent Diagnostic Testing Facility (IDTF)

Other

Last Updated Apr 15, 2026