Billing 93965 with 93970

This multiple scan billing question has come up and caused a little controversy. Let me try to make it a little clearer.

First the basics:
93965 is defined as Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g. Doppler waveform analysis with responses to phleborheography impedance plethysmography). This is a non-imaging study in response to compression and other maneuvers.

93970 is defined as Duplex scan of lower extremity veins including responses to compression and other maneuvers, complete bilateral study. This is both an imaging and non-imaging study. It includes the collection of BOTH physiologic in the form of Doppler analysis of bi-directional blood flow, the spectrum analysis, and B-mode imaging.

The two services are done with different equipment. 93970 is a study done with newer technology, more comprehensive and inclusive of the old study performed when billing 93965. Because they are different tests, done on different machines, they are technically not subject to a Correct Coding Initiative edit by Medicare, and can be billed together on the same day.

However, it is considered unnecessary testing to order both services on the same day when one service is sufficient to diagnose the patient (93970) as it is the more comprehensive test. CMS (Centers for Medicare and Medicaid services) considers the practice of performing both to be fraudulent billing.

One example is the FL Whistleblower case: Case No. 2:00-CV-558-FTM-29DNF
Radiology Regional Center (RRC), agreed to pay a 2.5 million dollar settlement on 06/23/2004 for filing false Medicare claims. The suit alleged that RRC billed for two venous or arterial studies on the same date that were not properly billable. Codes sited in this case as not being allowed to be billed together included, but were not limited to, 93965/ 93970 and 93965/ 93971.

A quote from this case: “This settlement again demonstrates the United States commitment to protecting federal funds from fraud,” said Peter D Keisler, Asst. Attorney General in charge of the civil division. A strong deterrent from ordering, and billing unnecessary testing…”

More research found multiple settlement cases for billing in the same fashion around the country. The penalties for this type of billing can amount to extremely large fines and possible revocation of license to practice medicine. Both consequences are not worth the few extra dollars this type of billing will net.

The inherent problem is not the question of if these services CAN be billed together, but if they SHOULD be billed together. According to CMS, it is not a condoned practice to order additional testing that is ultimately not needed to diagnose and treat a patient. If you do insist on performing both tests, then your documentation must reflect that both tests were performed, and have a definitive reason for doing so.

Written by:

Cheryl A. Nash, CIBS
Director of Operations
American Physician Financial Solutions

A.J. Riviezzo, MBA
Chief Executive Officer
American Physician Financial Solutions