Diagnostics

Upper/Lower Venous Duplex

Diagnosing the

Upper/Lower Extremity Veins

The veins of the upper and lower extremities function to collect venous blood from the tissue capillaries and transport it back to the right side of the heart for reoxygenation in the lungs and filtration in the liver and kidneys. The venous systems are designed to transport large volumes of blood at very low pressures. Venous blood that exits the tissue capillaries is depleted of oxygen and nutrients, and contains large amounts of carbon dioxide and toxic metabolic wastes.  The venous blood collects in tiny venules, then small unnamed veins, and finally to larger named veins as it returns to the heart. All unnamed and named veins within the extremities contain one-way valves to assist in transportation against gravity back to the heart at surprisingly low pressures.

There are two venous systems in the extremities – the deep venous system and the superficial venous system.  The deep venous system is located next to the bones deep within the muscles and enveloping fascia. They are very well-supported and therefore only rarely dilate or reflux.  Because the deep veins are located within the muscles, normal muscular contraction propels the blood up and out of the extremity. The deep veins normally transport about ninety percent of the spent blood out of the extremities. The superficial veins lie between the skin and the underlying muscular fascia.  They function more as a collecting system than a transporting system, and only convey about ten percent of the blood out of the extremity.  They are poorly supported and thus prone to dilation and valvular failure with subsequent reflux and dramatic increases in venous pressure.

Venous Disease

Veins are prone to two types of disease: blood clots and valvular failure.  Both of these conditions can hamper the normal return of venous blood back to the heart, a condition known as venous insufficiency. Venous insufficiency can lead to high venous pressures that are transmitted back to the capillary bed with damaging results in the delicate capillaries and tissues.

Both the deep venous system and the superficial venous system can develop blood clots. Blood clots can cause venous insufficiency in two ways. If the clot is large and fails to dissolve, it can cause obstruction of the vein with an increase in venous pressure.  If the clot does dissolve but damages the valves within the vein, it can cause venous reflux, or abnormal movement of venous blood away from the heart by the force of gravity.  Both of these processes can cause high venous pressures.

The most common cause of venous insufficiency is valvular failure and subsequent venous reflux. Because of the deep venous system’s location deep within the extremity, it is well-supported by surrounding bone, muscle, and muscular fascia.  The deep veins are therefore resistant to valvular failure (except when caused by deep venous thrombosis).  The superficial venous system is located in the subcutaneous space between the skin and the muscular fascia and is poorly supported.  The superficial veins are therefore quite prone to dilation and valvular failure with resulting venous reflux. 

The biggest risk factor for developing venous insufficiency from valvular failure is an inherited weakness in the vein walls and valves.  The incidence of valvular failure is particularly high when a genetic predilection is combined with other risk factors such as advanced age, a career that requires prolonged standing or sitting, obesity, etc.

Venous Ultrasound Examination

Duplex ultrasound examination of the veins of the upper or lower extremities is performed to evaluate for venous thrombus and venous reflux in the deep and superficial venous systems.  Venous duplex ultrasound uses real-time imaging and color Doppler to evaluate the structure and function of the named veins in about 30 minutes. Because duplex technology allows evaluation of the blood flow as well as the venous structure, it is considered the gold standard in evaluating the venous systems of the extremities. Because it does not use ionizing radiation, duplex ultrasonography is considered harmless and can be safely used with pregnant patients and patients of any age.There is no required prep and NPO is not necessary.

Diagnosis

Indications

  • Aching / pain
  • Swelling
  • Restless Legs Syndrome
  • Superficial venous thrombosis (thrombophlebitis)
  • Lower extremity cellulitis
  • Chest pain with shortness of breath
  • Brawny edema
  • Lower extremity eczema
  • Non-healing leg ulcer

Common Findings

  • Deep venous thrombosis (DVT)
  • Superficial venous thrombosis (SVT)
  • Venous reflux
  • Baker’s cyst
CPT Codes
  • 93970 – Duplex scan of extremity veins, complete bilateral study

  • 93971 – Duplex scan of extremity veins, unilateral or limited study

Common ICD-10 Codes
  • 93970 – DUPLEX UPPER OR LOWER EXTREMITY VEINS

  • M79.601 – Pain in right arm

  • M79.602 – Pain in left arm

  • M79.604 – Pain in right leg

  • M79.605 – Pain in left leg

  • R06.02 – Shortness of Breath

  • R60.0 – Localized edema

  • R60.1 – Generalized edema

  • R60.9 – Edema, unspecified

  • I82.401 – Acute embolism / thrombosis of unspecified deep veins of (R) lower extremity

  • I82.402 – Acute embolism / thrombosis of unspecified deep veins of (L) lower extremity

  • M71.20 – Synovial cyst of popliteal space [Baker], unspecified knee

  • I83.11 – Varicose veins of right lower extremity with inflammation

  • I83.12 – Varicose veins of left lower extremity with inflammation

  • I80.0 – Phlebitis / thrombophlebitis of superficial vessels of lower extremities

  • R07.82 – Intercostal pain

  • R07.89 – Other chest pain

  • I70.232 – Atherosclerosis of native arteries of right leg with ulceration of calf

  • I70.242 – Atherosclerosis of native arteries of left leg with ulceration of calf

  • I82.411 – Acute embolism and thrombosis of right femoral vein

  • I82.412 – Acute embolism and thrombosis of left femoral vein

  • I82.413 – Acute embolism and thrombosis of femoral vein, bilateral

  • I82.419 – Acute embolism and thrombosis of unspecified femoral vein

  • I82.421 – Acute embolism and thrombosis of right iliac vein

  • I82.422 – Acute embolism and thrombosis of left iliac vein

  • I82.423 – Acute embolism and thrombosis of iliac vein, bilateral

  • I82.429 – Acute embolism and thrombosis of unspecified iliac vein

  • I82.431 – Acute embolism and thrombosis of right popliteal vein

  • I82.432 – Acute embolism and thrombosis of left popliteal vein

  • I82.433 – Acute embolism and thrombosis of popliteal vein, bilateral

  • I82.439 – Acute embolism and thrombosis of unspecified popliteal vein

  • I82.4Y1 – Acute embolism / thrombosis of unspecified deep veins of (R) lower extremity

  • I82.4Y2 – Acute embolism / thrombosis of unspecified deep veins of (L) lower extremity

  • I82.4Y3 – Acute embolism / thrombosis of unspecified deep veins of (B)lower extremity

  • I87.2 – Venous insufficiency (chronic) (peripheral)

  • I87.9 – Disorder of vein, unspecified

  • L02.415 – Cutaneous abscess of right lower limb

  • L02.416 – Cutaneous abscess of left lower limb

  • L02.419 – Cutaneous abscess of limb, unspecified

  • L03.115 – Cellulitis of right lower limb

  • L03.116 – Cellulitis of left lower limb

  • L03.119 – Cellulitis of unspecified part of limb

  • L03.125 – Acute lymphangitis of right lower limb

  • L03.126 – Acute lymphangitis of left lower limb

  • L03.129 – Acute lymphangitis of unspecified part of limb

  • L53.9 – Erythematous condition, unspecified

  • L97.201 – Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin

  • L97.202 – Non-pressure chronic ulcer of unspecified calf with fat layer exposed

  • L97.203 – Non-pressure chronic ulcer of unspecified calf with necrosis of muscle

  • L97.204 – Non-pressure chronic ulcer of unspecified calf with necrosis of bone

  • L97.209 – Non-pressure chronic ulcer of unspecified calf with unspecified severity

  • L97.211 – Non-pressure chronic ulcer of right calf limited to breakdown of skin

  • L97.212 – Non-pressure chronic ulcer of right calf with fat layer exposed

  • L97.213 – Non-pressure chronic ulcer of right calf with necrosis of muscle

  • L97.214 – Non-pressure chronic ulcer of right calf with necrosis of bone

  • L97.219 – Non-pressure chronic ulcer of right calf with unspecified severity

  • L97.221 – Non-pressure chronic ulcer of left calf limited to breakdown of skin

  • L97.222 – Non-pressure chronic ulcer of left calf with fat layer exposed

  • L97.223 – Non-pressure chronic ulcer of left calf with necrosis of muscle

  • L97.224 – Non-pressure chronic ulcer of left calf with necrosis of bone

  • L97.229 – Non-pressure chronic ulcer of left calf with unspecified severity

  • R23.0 – Cyanosis

  • I83.009 – Varicose veins of unspecified lower extremity with ulcer of unspecified site

  • I83.019 – Varicose veins of right lower extremity with ulcer of unspecified site

  • I83.029 – Varicose veins of left lower extremity with ulcer of unspecified site

  • R07.1 – Chest pain on breathing

  • R07.81 – Pleurodynia

  • I26.99 – Other pulmonary embolism without acute cor pulmonale

  • Z86.72 – Personal history of thrombophlebitis

  • Z01.810 – Encounter for preprocedural cardiovascular examination

  • Z99.2 – Dependance on renal dialysis

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