Comments on a Proposed LMRP:
Empire Medical / New Jersey

This letter can serve as a model on commenting on a local medical review policy (LMRP). Because all proposed LMRPs will vary to some extent, you will need to adopt this model to your specific situation.

July 25, 2001
Eileen Moynihan, M.D.
Empire Medical Services
1333 Brunswick Avenue
Lawrenceville, NJ 09086

Dear Dr. Moynihan,

The Society of Vascular Technology would like to take this opportunity to comment on the LMRP titled "Non-Invasive Vascular Diagnostic Studies," from Empire State Services NJ, contractor policy number M-48 A. We are writing to express SVT's basic support for this LMRP but do note disagreement with several of its components. We thank for your commitment to the Medicare program and to the beneficiaries whom we, too, serve. We are eager to work with you to establish appropriate medical review policies.

SVT was founded in 1977, is one of the oldest professional societies for vascular technologists and sonographers, and is the only professional organization completely dedicated to the advancement of non-invasive vascular technology in the diagnosis of vascular disease. SVT is comprised of more than 4,000 members, including 1,000 physicians and 3,000 vascular technologists.

Regarding credentialing, we take this opportunity to note that SVT and other organizations representing sonographers (the Society of Diagnostic Medical Sonographers [SDMS], and the American Institute for Ultrasound in Medicine [AIUM] recently approved a new "Scope of Practice for Diagnostic Ultrasound Professionals". This document discusses the nature of the work undertaken by ultrasound professionals providing technical component services. It specifically indicates that ultrasound professionals should obtain credentials that are awarded by an agency certified by the National Commission for Certifying Agencies (NCCA).

Specifically, our concerns regarding personnel certification are included in the section LMRP Description, paragraph five. The Registered Cardiovascular Technologist (RCVT) credential in vascular technology has been replaced with the Registered Vascular Specialist (RVS) credential. Therefore title RCVT should be removed. The American College of Radiology (ACR) offers facility accreditation. It does not credential individuals.

In addition to our concern in reference to personnel credentialing, we have noted several ICD-9 that we put forth for review. These concerns are summarized below:

• 780.4, dizziness, should be included in the list of appropriate ICD-9 codes for cerebrovascular examinations Admittedly, the most common causes of episodic dizziness are related to transient cerebrovascular insufficiency secondary to transiently decreased cardiac output or postural hypotension. However, when these etiologies have been previously excluded (e.g. by cardiac events monitoring), and the symptom characteristics are those of transient ischemic attacks (TIA), it has long been recognized that examination of the cerebrovascular circulation for a possible source may be appropriate. For example, a study published in the Journal of American Medical Association (November 28, 1977, Volume 238, page 2388) provides a detailed review of the distribution of common symptoms among TIA diagnoses. With regard to dizziness clinically diagnosed as TIA, review of 98 cases demonstrated that 56 patients demonstrated a source of dizziness in the cerebrovascular circulation (ten in the right carotid system, five in the left carotid system, and 41 in the vertebrobasilar system).
  
  Given that a majority of this well-selected patient population have episodic dizziness secondary to arterial occlusive disease, we highly recommend you consider (1) include 780.4 as an appropriate code, and (2) additional text in the body of the LMRP providing an explanation of when the use of this ICD-9 code might be considered appropriate. This has been similarly provided by a number of other Medicare Carriers in LMRP. For example, the LMRP used in Arkansas Blue Cross Blue Shield in Louisiana, and repeated by several other carriers, states: "Dizziness is not a typical indication unless associated with other localizing signs and symptoms. However, episodic dizziness with symptom characteristics typical of transient ischemic attack may indicate medical necessity, especially when other more common sources (e.g. postural hypotension or transiently decreased cardiac output as demonstrated by cardiac events monitoring) have been previously excluded."
• · V58.49 is listed with ICD-9 codes under the extremity arterial studies category. This is an inappropriate code for non-invasive vascular technology. It should be replaced throughout the LMRP with V67.09, following other surgery.
• · The list of acceptable ICD-9 codes in the visceral vascular examination section is not extensive or comprehensive. SVT suggests that section be totally eliminated or dramatically expanded to include all ICD-9 codes relevant to visceral abnormalities. This list should include codes regarding signs and symptoms of abnormalities of the all organs and vessels in the abdomen, retroperitonieum and pelvis. It is because this will result in numerous codes, SVT highly suggests eliminating this section of codes all together.

SVT thanks you in advance for reviewing our comments and concerns. We look forward to your response in these matters.

Sincerely,

Patricia Marques, RN, RVT, FSVU
President
Society of Vascular Technology

Anne Jones, BSN, RN, RVT, RDMS, FSVU
Legislative Chair
Society of Vascular Technology