Comments on a Proposed LMRP
Rhode Island—2nd Comment

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.

Read the response to the letter to see how your comments can make an impact on LMRPs.

November 29, 2000

Parker Staples, M.D.
Medicare Contractor Medical Director
Medicare Department
Blue Cross Blue Shield of Rhode Island
444 Westminster Street
Providence, RI 02903-3279
VIA FAX (401-459-1709)

Dear Dr. Staples:

On behalf of the Society of Vascular Technology (SVT), we want to thank you for your consideration of our July 12, 2000 letter. We wrote to you on behalf of our Rhode Island physician, nurse, and technologist members. Over the past decade, SVT has been actively involved in communicating with the Health Care Financing Administration (HCFA), both in response to proposed rule-making and in other circumstances. Increasingly, our members in various states, including Rhode Island, are requesting our assistance in commenting on local medical review policies (LMRPs). We have always appreciated the ability to work with national and local Medicare program policy-makers, such as yourself, and we want to thank you for your service to the Medicare beneficiaries that our members also have the privilege to serve.

We also appreciated your comments on CPT code 93875 (non-invasive studies of extracranial arteries). Carotid endarterectomy is commonly being performed without antecedent arteriography. This is well recognized; however, duplex scanning has a maximum accuracy of approximately 90% with a positive predictive value of approximately 90%. Using duplex as the only basis for carotid endarterectomy, conceivably 1 out of 10 carotid endarterectomies will be unnecessary on the basis of duplex criteria alone. The Asymptomatic Carotid Artery Stenosis Study (ACAS) recognized this and as a result, altered their selection criteria. The study design was altered to include 93875 in the selection process used in this multi-centered clinical trial. In the hands of the experienced examiner, this is a valuable tool.

As we understand your letter, you are indicating an interest in bundling CPT code 93875 and certain other services when performed on the same date of service, without permitting the services to be separately payable where appropriate modifiers, such as modifier -59, are used. We do not believe that the National Correct Coding Initiative ("NCCI"), a national policy that preempts carrier-specific differences, would permit this. NCCI-approved bundling of CPT code 93875 occurs when CPT codes 93875 and 93880 (duplex scan of extracranial arteries; complete bilateral study) are billed on the same day. In that circumstance, NCCI states that CPT code 93875 is a component code and is bundled into CPT code 93880, the comprehensive code. However, the NCCI allows providers to bypass the edit with an appropriate modifier, such as modifier -59.

You also proposed bundling CPT codes 93875 and 93882 (duplex scan of extracranial arteries; unilateral or limited study). The NCCI does not bundle CPT code 93875 into CPT code 93882. Therefore, these codes may not be bundled in an LMRP.

If your office finds that some providers are abusing CPT code 93875, e.g., by billing this code when the only Doppler study they performed was part of the duplex scan, the carrier can implement audits to control this situation. We would be happy to assist in educational efforts on this topic as well.

Regarding credentialing, we take this opportunity to note that SVT and other organizations involved in ultrasound services (the Society of Diagnostic Medical Sonographers (SDMS), the American Institute for Ultrasound in Medicine (AIUM), the American Society of Echocardiography (ASE), and the Canadian Society of Diagnostic Medical Sonographers (CSDMS)) recently approved a new "Scope of Practice for Diagnostic Ultrasound Professionals." We have enclosed that document for your review and consideration. This document discusses the nature of the work undertaken by ultrasound professionals providing technical component services. It specifically indicates that credentialing is a standard that should be obtained by ultrasound professionals. It also describes the important discretionary functions undertaken by ultrasound professionals and the need for ultrasound professionals to act with an important measure of independence.

We were particularly interested in your comments on your authority to implement a credentialing standard as part of the LMRP. It sounds as though our letter to you did not convey our suggestion as we had intended. We apologize for this. We are not suggesting that the LMRP should establish the credentialing standard as a PRO quality of care initiative (which we understand would not be possible). Instead, we are asking you to consider implementing it pursuant to your authority to define medical necessity and reasonable and necessary services.

Approximately 17 Medicare carriers have used their "medical necessity" authority to implement the kind of credentialing standards that we believe would serve the interests of the Medicare program and its beneficiaries in Rhode Island. These jurisdictions include Alabama, Delaware, Greater Washington (District of Columbia, Northern Virginia, Prince George's County and Montgomery County in Maryland), Iowa, Kansas, Louisiana, Maryland, Mississippi, Western Missouri, Nebraska, New Jersey, New York Southeast, Ohio, Pennsylvania, Puerto Rico, South Carolina, Texas, and West Virginia. [Can we add Indiana?]

Moreover, HCFA has established the precise credentialing standard that we seek for Independent Diagnostic Testing Facilities ("IDTFs") in the final rule issued October 31, 1997. That rule specifically ties the credentialing requirement to the program's medical necessity authority. We understand that the Office of General Counsel for the Department of Health and Human Services has offered its opinion that the exercise of medical necessity authority in connection with a credentialing standard is valid and appropriate.

We urge you to issue a policy that requires all persons providing vascular ultrasound services to be credentialed as a Registered Vascular Technologist ("RVT"), or a Registered Vascular Specialist ("RVS"). We also suggest that such a credentialing requirement be extended to other ultrasound services.

We very much agree with your goal of eliminating any abusive practices that may exist. We believe that this goal will be best furthered by ensuring that the persons providing the services are properly trained about the circumstances in which ultrasound services should and should not be performed. Our experience and the experience of HCFA following the introduction of the IDTF rule is that credentialed personnel are advocates for appropriate utilization of services.

Very truly yours,

Michael Yablonski, RVT
Chair, SVT CMD Network for Rhode Island

cc: Anne Jones, BSN RN RVT RDMS FSVU,Chair, SVT Govt. Relations Committee
Frank West, RN RVT FSVU, SVT Regulatory Advisor
Christy Cornwell, LPN RVT, Advisor, SVT CMD Network
SVT Board of Directors
Suzanne Stone, Esq., SVT Executive Director