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Section: Diagnostic Medical
Number: M-14
Topic: Non-Invasive Vascular Diagnostic Studies
Effective Date: August 1, 2005
Issued Date: September 10, 2007
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

  1. Cerebrovascular Arterial Studies

    Non-invasive physiologic studies of extracranial arteries (code 93875) may include one or more of the following:

    • Periorbital flow direction with arterial compression
    • Ocular plethysmography with brachial blood pressure
    • Analog velocity waveform spectral analysis, Doppler ultrasound evaluation

    Indirect periorbital studies, whether Doppler, photoplethysmography (PPG), or ocular pneumoplethysmography (OPG), should be reported under code 93875.

    Direct carotid studies without imaging, whether continuous wave (CW) Doppler spectrum analysis, CPA, analog Doppler waveform analysis, or vertebral flow direction study, should be reported under code 93875.

    Procedure code 93875 is considered a component of the more complex duplex study of the extracranial arteries (code 93880) when they are performed on the same day.

    Direct carotid studies with some form of imaging, whether CW or pulsed Doppler imaging or real-time B-mode high resolution imaging, with or without spectrum analysis, should be reported under codes 93880 or 93882, as appropriate.

  2. Extremity Arterial Studies Including Digits

    Non-invasive physiologic studies of upper or lower extremity arteries (codes 93922-93931, 93990) may include two or more of the following:

    • Segmental blood pressure measurements
    • Continuous wave Doppler analog wave form analysis or pulse volume recording analysis
    • Evocative pressure response to exercise or reactive hyperemia
    • Photoplethysmographic or pulsed volume digit wave form analysis
    • Flow velocity signals
    • Angiodynogram

    Payment should not be made for more than one extremity arterial study (93922-93924) on the same extremity on the same day.

  3. Extremity Venous Studies Including Digits

    Non-invasive physiologic studies of extremity veins (code 93965) may include one or more of the following:

    • Continuous Doppler studies with evaluation of venous flow patterns and responses to compression and other maneuvers
    • Phleborheography
    • Impedance plethysmography
    • Quantitative photoplethysmography
    • Angiodynogram

    Procedure code 93965 is considered a component of the more complex study duplex scan of extremity veins (code 93970) when they are performed on the same day.

  4. Visceral and Penile Vascular Studies

    Visceral and penile vascular studies (codes 93975-93981) are effective as diagnostic tools. However, routine screening is not a covered service because it is performed without relationship to a specific illness, symptom, complaint, or injury.

    Plethysmography is valuable as a non-invasive technique for diagnosing peripheral arterial disease as well as pre-operative and post-operative evaluation for vascular surgery. It is also useful for pre-operative evaluation of a diabetic patient or one with intermittent claudication or other symptoms indicative of peripheral vascular disease which would have a bearing on the patient's candidacy for foot surgery.

    The following guidelines should be applied to claims for non-invasive vascular studies:

    1. Codes (93875 - 93990) are considered total studies and should be reported as a single study whether they are done unilaterally or bilaterally.

    2. All precerebral arterial studies (i.e., brachiocephalic, subclavian, vertebral) except the aorta or upper extremity arteries distal to the subclavian artery should be processed under code 93875.

    3. Payment may be made for plethysmography of the extremities only by the volume, impedance, or strain gauge methods. The photoelectric method is used for studying venous insufficiency and venous reflux. It is also useful in studying the supraorbital arteries and digital arteries in association with other studies. Plethysmography by other means (e.g., inductance plethysmography, capacitance plethysmography, mechanical oscillometry, bionic plethysmography) is not eligible for reimbursement.

    4. It is not common practice to perform peripheral vascular studies on the arms and legs at the same time. The following diagnoses/conditions have been identified as those justifying payment for upper extremity arterial studies when performed at the same time as lower extremity arterial studies (This is not intended to be an all-inclusive list.):
      1. Raynaud's-like symptoms (intermittent attacks of pallor or cyanosis of the digits, usually the fingers);
      2. thoracic outlet disorders;
      3. thromboembolism;
      4. selected patients with arteriovenous shunts for dialysis;
      5. patients requiring axillofemoral bypass;
      6. subclavian steal syndrome;
      7. upper extremity arterial trauma including medical catheterization and indwelling arterial lines;
      8. upper extremity atherosclerosis;
      9. Buerger's disease; and
      10. arteritis syndromes (Takayasu's giant cell, etc.)

    5. While it is unusual, there are instances when venous and arterial studies of the extremities could be done on the same day. If such services are reported, payment may be made for both the venous and the arterial studies.

    6. If intraoperative transcranial Doppler (TCD) is reported on the same day with surgical care and the charges are itemized, combine the charges and pay only the surgical care. Payment for the surgical care performed on the same date of service includes an allowance for the TCD study. A participating, preferred, or network provider cannot bill the member separately for the TCD study in this instance.

    If the TCD study is performed independently, process it under codes 93886, 93888, 93890, 93892, or 93893, as appropriate.


Non-invasive vascular studies include supervision of the studies and interpretation of study results with copies for patient records of hard copy output with analysis of all data, including bidirectional vascular flow or imaging when provided. These studies also include patient care required to perform the studies. The use of a simple hand-held or other Doppler device that does not produce hard copy output, or that produces a record that does not permit analysis of bidirectional vascular flow, is considered part of the physical examination of the vascular system and is not separately reported.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes


Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines



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[Version 001 of M-14]

Table Attachment

Text Attachment

Procedure Code Attachment


Continuous Wave (CW) Doppler

An instrument which emits an ultrasound beam without interruption. CW detects flow at any depth of penetration governed by the frequency of the probe.


A diagnostic instrument which emits an ultrasound beam into the body. This ultrasound is reflected back from moving structures within the body at a frequency higher or lower than this transmitted frequency (Doppler shift). This shift is amplified and presented as a sound, graphic (chart), or spectral display.

Duplex Scan

An ultrasonic scanning procedure with display of both two-dimensional structure and motion with time and Doppler ultrasonic signal documentation with spectral analysis and/or color flow velocity mapping or imaging.

Impedance Plethysmography

This method senses changes in a minute electric current sent through a portion of the body by means of separate electrodes proximal and distal to the sensing electrodes. Changes in electrical impedance of a limb are a reflection of the change in blood content and limb


A Doppler instrument which assesses flow, via frequency shift, without regard for direction of the blood flow.

Oculoplethysmography (OPG)

A procedure by which changes in eye volume as related to arterial blood flow are detected and recorded. Blood flow to the eye is stopped using suction during this procedure.

Periorbital Doppler

An examination utilizing the Doppler in the periorbital region to assess flow direction in the frontal and superorbital arteries, and flow reaction upon compression of various external artery branches.

Phonoangiography, Carotid (CPA)

Records the intensity of carotid bruits during systolic or diastolic phases. Helps in identifying the presence, site, and severity of carotid artery occlusive disease.

Photoplethysmography (PPG)

Detects changes in the blood content of skin and subcutaneous tissue by measuring the varying amounts of light reflected from red blood cells.


An instrument which measures volume change through a change in quantity of blood therein. Types: air, impedance, strain gauge, and photo.

Pulsed Volume Recorder (PVR)

A segmental air plethysmography which employs changes in cuff pressure to indicate changes in limb volume due to blood flow.

Strain Gauge Plethysmography

A procedure which assesses blood flow through detection of limb volume changes as reflected by impedance changes in an elastic tube filled with an electro-conductive metal, placed around the limb being examined.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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