Local Coverage Determination (LCD):
Autonomic Function Tests (L31465)
Contractor Name
First Coast Service Options, Inc.
Document Information
LCD ID
L31465
Original Effective Date
LCD Title
For services performed on or after 01/23/2011
Autonomic Function Tests
Revision Effective Date
AMA CPT/ADA CDT Copyright Statement
For services performed on or after 03/24/2014
CPT only copyright 2002-2013 American Medical Association. All
Rights Reserved. CPT is a registered trademark of the American
Revision Ending Date
Medical Association. Applicable FARS/DFARS Apply to
N/A
Government Use. Fee schedules, relative value units, conversion
factors and/or related components are not assigned by the AMA,
are not part of CPT, and the AMA is not recommending their use.
The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data
Retirement Date
N/A
Notice Period Start Date
02/07/2014
contained or not contained herein. The Code on Dental
Procedures and Nomenclature (Code) is published in Current
Dental Terminology (CDT). Copyright © American Dental
Notice Period End Date
03/24/2014
Association. All rights reserved. CDT and CDT-2010 are
trademarks of the American Dental Association.
CMS National Coverage Policy
Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized
throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD
Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See
§1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:
CMS Manual System, Pub. 100-02, Medicare Benefit Policy, Chapter 15, Section 80.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
The autonomic nervous system (ANS) is a regulatory branch of both the central and peripheral nervous system, which controls and
regulates the autonomic functions within the body through sympathetic and parasympathetic nerves. These functions include regulation
of blood pressure, heart rate, airway size and airflow to the lungs, digestive tract functions, sweat production, bladder control, and sexual
function. The ANS acts through a balance of its own two components, the sympathetic and parasympathetic nervous systems.
Autonomic failure consists of impaired or absent function of autonomic responses, which may be sympathetic or parasympathetic or both
and can involve specific organ systems or can be generalized. There are other autonomic disorders that consist of excessive function of
autonomic responses. The concept of an imbalance between opposing autonomic systems is applicable to some disorders, such as
some cardiac arrhythmias, but not in all autonomic disorders. Autonomic disorders may be congenital or acquired – primary or
secondary. If it becomes unbalanced, a person may experience a variety of symptoms that are sometimes vague and can affect many
bodily functions. To the specialist, the presentation of autonomic dysfunction can be specific and diagnosed with simple clinical tests.
Autonomic testing, properly performed and interpreted, is helpful toward achieving diagnostic specificity. Autonomic failure is associated
with increased morbidity and mortality. Orthostatic hypotension is associated with an increased risk of falls and impairment in activities of
daily living.
ANS testing can be grouped into the following general catagories:
1.
Cardiovagal innervation (CPT code 95921) – a test that provides a standardized quantitative evaluation of vagal innervation to
parasympathetic function of the heart. Responses are based on the interpretation of changes in continuous heart recordings in response
to standardized maneuvers and include heart rate response to deep breathing,
Valsalva ratio, and 30:15 ratio heart rate responses to standing.
2.
Vasomotor adrenergic innervation (CPT code 95922) – evaluates adrenergic innervation of the circulation and of the heart in autonomic
failure. The following tests are included: beat-to-beat blood pressure and R-R interval response to Valsalva maneuver, sustained hand
grip, and blood pressure and heart rate responses to tilt-up or active standing.
3.
Sudomotor (CPT code 95923) – function testing is used to evaluate and document neuropathic disturbances that may be associated with
pain. The quantitative sudomotor axon reflex test (QSART), thermoregulatory sweat test (TST), sympathetic skin responses, and silastic
sweat imprints are tests of sympathetic cholinergic sudomotor function.
The QSART measures axon reflex-mediated sudomotor responses quantitatively and evaluates post-ganglionic sudomotor function.
Recording is usually carried out from the forearm and three lower extremity skin sites to assess the distribution of post-ganglionic deficits.
The TST evaluates the distribution of sweating by a change in color ofan indicator powder. This test has a high sensitivity, and its
specificity for delineating the site of lesion is greatly enhanced when used in conjunction with QSART.
Sweat imprints are formed by the secretion of active sweat glands into a plastic (silastic) imprint. The test can determine sweat gland
density, a histogram of sweat droplet size and sweat volume per area.
4.
Combined cardiovagal and vasomotor adrenergic innervation testing (CPT code 95924) of the autonomic nervous system is specifically
of parasympathetic function and vasomotor adrenergic function using at least a 5-minute tilt with a passive tilt table.
Indications:
Appropriate application and interpretation of ANS testing requires a detailed knowledge of the testing criterion and a match between the
tests of suspected clinical/functional impairment with the autonomic activity being tested. Most autonomic disorders are diagnosed
clinically, with laboratory and formal diagnostic testing when ordered and performed appropriately playing both a primary diagnostic and
an adjunctive or confirmatory role. Testing may also be appropriate to monitor disease progression when there is a change in clinical
status or to evaluate a patient’s response to specific treatment for an autonomic disorder.
Autonomic function testing is covered as reasonable and necessary when used as a diagnostic tool to evaluate symptoms indicative of
vasomotor instability, such as hypotension, orthostatic tachycardia, and hyperhidrosis after more common causes have been excluded
by other testing, and the ANS testing is directed at establishing a more accurate or definitive diagnosis or contributing to clinically useful
and relevant medical decision making for one of the following indications:
1. To diagnose the presence of autonomic neuropathy in a patient with signs or symptoms suggesting a progressive autonomic
neuropathy.
2. To evaluate the severity and distribution of a diagnosed progressive autonomic neuropathy.
3. To differentiate the diagnosis between certain complicated variants of syncope from other causes of loss of consciousness.
4. To evaluate inadequate response to beta blockade in vasodepressor syncope.
5. To evaluate distressing symptoms in a patient with a clinical picture suspicious for distal small fiber neuropathy in order to diagnose
the condition.
6. To differentiate the cause of postural tachycardia syndrome.
7. To evaluate change in type, distribution, or severity of autonomic deficits in patients with autonomic failure.
8. To evaluate the response to treatment in patients with autonomic failure who demonstrate a change in clinical exam.
9. To diagnose axonal neuropathy or suspected autonomic neuropathy in the symptomatic patient.
10. To evaluate and treat patients with recurrent unexplained syncope to demonstrate autonomic failure, after more common causes
have been excluded by other standard testing.
Equipment for Autonomic Nervous System Studies
General professional standards apply for all equipment. Unknown algorithms untested on the Medicare population in systematic trials do
not constitute the professional component of diagnostic testing. Equipment with FDA clearance for heart rate variability measurements in
response to paced respirations and exercises that tests only heart rate variability does not meet the full range of testing parameters
required for the performance of 95921 and 95922 and does not ensure full test requirements, such as blood pressure monitoring, nor do
they incorporate proper testing conditions, such as the use of a tilt table. Providers may be asked to supply information on the equipment
used to perform autonomic nervous system studies to ensure that all studies performed meet the requirements of the procedure.
Limitations:




Syndromes of autonomic dysfunction for which ANS testing might add valuable clinical information are relatively rare. Generally, only
after excluding more common causes of autonomic signs or symptoms (e.g., hypotension, hyperhidrosis, and orthostatic tachycardia)
may formal autonomic testing be indicated to exclude or confirm autonomic disorders. The following indications are not considered
medically reasonable and necessary and will not be covered:
To screen patients without signs or symptoms of autonomic dysfunction, including patients with diabetes, hepatic, or renal disease;
Testing for the sole purpose of monitoring disease intensity or treatment efficacy in diabetes, hepatic, or renal disease;
Testing where the results are not used in clinical decision-making and patient management;
Testing performed by physicians who do not have evidence of training and expertise to perform and interpret these tests. Testing must
be done for an accepted clinical indication by a properly trained examiner and interpreted by qualified individuals within their scope of
practice (weekend courses may not demonstrate expertise). Physicians must have knowledge, training, and expertise to perform and
interpret these tests, and to assess and train personnel working with them. This training and expertise must have been acquired within
the framework of an accredited residency and/or fellowship program or must reflect extensive continued medical education activities. If
these skills have been acquired by way of continued medical education, the courses must be comprehensive and designated for the
American Medical Association (AMA) category I credit by an ACCME (Accreditation Council for Continuing Medical Education) or SMS
(State Medical Society) accredited CME provider.
CPT code 95943, for example Ansar (ANX 3.0), is not medically reasonable and necessary since it is not proven that this type of testing
is at least as beneficial as existing and available medically appropriate testing alternatives. The clinical validity and clinical utility of these
technologies have not been established. The qualifications of the personnel performing the testing are not standardized. If a physician
finds that this non-standardized component information of autonomic function testing is useful in a patient assessment and clinical
decision making given certain patient risks/signs/symptoms, this would be included in the physician’s basic evaluation and management
service and not separately covered. When patients have significant symptoms, the primary physician should consider referring to the
appropriate specialist or subspecialist for testing.
false
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type
does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not
influenced by Bill Type and the policy should be assumed to apply equally to all claims.
012x
Hospital Inpatient (Medicare Part B only)
013x
Hospital Outpatient
071x
Clinic - Rural Health
085x
Critical Access Hospital
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most
instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally
subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue
Code and the policy should be assumed to apply equally to all Revenue Codes.
092X
Other Diagnostic Services - General Classification
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; CARDIOVAGAL INNERVATION
(PARASYMPATHETIC FUNCTION), INCLUDING 2 OR MORE OF THE FOLLOWING: HEART RATE
95921
RESPONSE TO DEEP BREATHING WITH RECORDED R-R INTERVAL, VALSALVA RATIO, AND 30:15
RATIO
TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; VASOMOTOR ADRENERGIC
INNERVATION (SYMPATHETIC ADRENERGIC FUNCTION), INCLUDING BEAT-TO-BEAT BLOOD
95922
PRESSURE AND R-R INTERVAL CHANGES DURING VALSALVA MANEUVER AND AT LEAST 5
MINUTES OF PASSIVE TILT
TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; SUDOMOTOR, INCLUDING 1 OR MORE OF
95923
THE FOLLOWING: QUANTITATIVE SUDOMOTOR AXON REFLEX TEST (QSART), SILASTIC SWEAT
IMPRINT, THERMOREGULATORY SWEAT TEST, AND CHANGES IN SYMPATHETIC SKIN POTENTIAL
TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; COMBINED PARASYMPATHETIC AND
95924
SYMPATHETIC ADRENERGIC FUNCTION TESTING WITH AT LEAST 5 MINUTES OF PASSIVE TILT
ICD-9 Codes that Support Medical Necessity
Group 1 Paragraph: N/A
Group 1 Codes:
250.60 -
DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS
250.63
UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
277.30 AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS
277.39
333.0
OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA
337.00
IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED
337.09
OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY
337.20 -
REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED
337.29
SITE
356.4
IDIOPATHIC PROGRESSIVE POLYNEUROPATHY
356.8
OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
356.9
UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
458.0
ORTHOSTATIC HYPOTENSION
780.2
SYNCOPE AND COLLAPSE
780.8
GENERALIZED HYPERHIDROSIS
785.0
TACHYCARDIA UNSPECIFIED
ICD-9 Codes that DO NOT Support Medical Necessity
N/A
false
General Information
Associated Information
Documentation Requirements
General professional standards with FDA clearance apply for all equipment used in ANS testing. Providers may be asked to supply
information on the equipment used to perform ANS studies to ensure all studies performed meet the requirements of the procedure.
Medical record documentation maintained by the performing provider must clearly support the medical necessity for ANS testing as
well as the test reports and interpretation. Supportive documentation showing medically reasonable and necessary indications as
outlined in this LCD are expected to be documented in the medical record and be available upon request. This documentation
includes, but is not limited to, relevant medical history, physical examination, results of pertinent diagnostic tests or procedures, and
after more common causes of autonomic signs or symptoms have been excluded (see limitations section of LCD).
The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1
(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services are "ordered and/or
furnished by qualified personnel."
A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and
expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable
specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic
institution in the United States and/or by the applicable specialty/subspecialty society in the United States.
If the provider of the ANS studies is other than the ordering/referring physician/nonphysician practitioner, the provider of the service
must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician
practitioner’s order for the studies.
Utilization Guidelines
Diagnostic testing may be allowed once to confirm or exclude specific autonomic disease. For patients with diagnosed autonomic
disorders, repeat testing is governed by a change in clinical status or response to a therapeutic intervention. If a repeat test is
needed, it is not expected to exceed once per year.
Providers who perform these tests on an unusually high proportion of their patients, or at frequencies exceeding once per year may
be subject to medical review.
Sources of Information and Basis for Decision
Aetna Clinical Policy Bulletin # 0485: Autonomic Testing/Sudomotor Tests, 2013.
Aker, K. (2008). Complex regional pain syndrome: A review of diagnostic tools. Reflex Sympathetic Dystrophy Syndrome Association.
Retrieved August 4, 2010, from http://www.rsds.org/4/resources/CRPS_Diagnosis.htm.
American Academy of Neurology. (2010). Complex regional pain syndrome. Retrieved August 19, 2010, from
http://patients.aan.com/disorders/index.cfm?event=view&disorder_id=894
American Heart Association. Autonomic Nervous System. 2010.
Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. April
2005; 28(4):956-962.
CGS Administrators, LLC. LCD (L33249) Nervous System Studies – Autonomic Function, Nerve Conduction and Electromyography,
2013.
CPT Changes: An Insider’s View 2013.
Current Procedural Terminology (CPT) Assistant 2002 – 2008.
England, J., Gronseth, G., Franklin, F., Carter, G., Kinsella, L., Cohen, J. et al. (2009). Practice Parameter: Evaluation of distal
symmetric polyneuropathy: Role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Neurology 72:177184.
Maser RE, Lenhard MJ. Cardiovascular autonomic neuropathy due to diabetes mellitus: clinical manifestations, consequences, and
treatment. J Clin Endocrinol Metab. 2005 Oct;90(10):5896-5903.
Mayo Foundation for Medical Education and Research. (2001-2010). Amyloidosis. Retrieved August 19, 2010 at
http://www.mayoclinic.org/amyloidosis/
Neuroscience/Neurology Services – Greenwich hospital. Autonomic Function Laboratory, 2000-2010. Retrieved July 21, 2010, from
http://www.greenhosp.org/medicalservices_neuroscience_autonomic.asp
Tesfaye S, Boulton AJ, Dyck PJ, et al. Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and
treatments. Diabetes CareOct. 2010; 33(10):2285-2293.]
The Merck Manual for Healthcare Professionals. Autonomic Nervous System. The Merck Manuals online library, 2009. Retrieved July
21, 2010, from http://www.merck.com/mmpe/print/sec16/ch208/ch208a.html
UPMC Health Plan, Policy and Procedure Manual. Autonomic Nervous System Testing, 2009.
U.S. Food and Drug Administration (2012). Inspections, Compliance, Enforcement, and Criminal Investigations. Retrieved at
http://www.fda.gov/ICECI/EnforcementActions/WarningLetters/2012/ucm327893.htm
Vinik AI, Maser RE, Mitchell BD, Freeman R. Diabetic autonomic neuropathy. Diabetes Care. 2003; 26: 1553-1579.]
Wang, A., Fealey, R., Gehrking, T., & Low, P. (2008). Patterns of neuropathy and autonomic failure in patients with amyloidosis.
Mayo Clinic Proceedings, 83, (11), 1226-1230.
false
Revision History Information
Please note: The Revision History information included in this LCD prior to 1/24/2013 will now display with a Revision
History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after
1/24/2013 will display as a row in the Revision History section of the LCD and numbering will begin with "R2".
Revision
Revision
Reason(s) for
History
Revision History Explanation
History Date
Change
Number
03/24/2014
R2
Revision Number: 3

Publication: February 2014 Connection
Provider
Education/Guidance
LCR A2014-019
Explanation of Revision: Major revisions were made throughout the entire LCD. The
effective date of this revision is based on date of service.
01/01/2013
R1
Revision Number:2

Start Date of Comment Period:N/A
Start Date of Notice Period:01/01/2013
HCPCS
Addition/Deletion

Original Effective Date:01/01/2013
HCPCS/ICD9
Descriptor Change

LCR A2013-020
December 2012 Connection
Explanation of revision: Annual 2013 HCPCS Update. CPT codes 95924 and 95943
Narrative Change
and descriptors were added to the “CPT/HCPCS Codes” section. The effective date of
this revision is based on date of service.
Revision Number:1
Start Date of Comment Period:N/A
Start Date of Notice Period:07/01/2011
Revised Effective Date:06/14/2011
LCR A2011-062
June 2011 Connection
Explanation of Revision: Based on an outside request to clarify our current training
statement outlined in this LCD, language under the “Documentation Requirements”
section of the LCD has been deleted and replaced with a revised statement regarding
the qualification and training. Revisions will be effective based on process date.
Revision Number:Original
Start Date of Comment Period:09/30/2010
Start Date of Notice Period:12/09/2010
Original Effective Date: 01/23/2011
LCR A2010-063
December 2010 Bulletin
11/25/2012 - For the following CPT/HCPCS codes either the short description and/or
the long description was changed. Depending on which description is used in this
LCD, there may not be any change in how the code displays in the document:
95921 descriptor was changed in Group 1
95922 descriptor was changed in Group 1
95923 descriptor was changed in Group 1
false
Associated Documents
Attachments
Coding guidelines effec 3/24/14 (PDF - 56 KB )
Comment Summary 10/10/13-11/23/13 (a comment and response document) (PDF - 88 KB )
Related Local Coverage Documents
N/A
Related National Coverage Documents
N/A
Public Version(s)
Updated on 01/31/2014 with effective dates 03/24/2014 - N/A
Updated on 12/19/2012 with effective dates 01/01/2013 - 03/23/2014
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.
Coding Guidelines Autonomic Function Tests Part A
Form Date: 09/18/09 Page 1 of 2 1-3.2.41 MP Part B FL Draft LCD
FIRST COAST SERVICE OPTIONS CODING GUIDELINES
LCD Database ID Number
L31465
Contractor Name
First Coast Service Options, Inc.
Contractor Number
09101 - Florida
09201 – PR/USVI
LCD Title
Autonomic Function Tests
Coding Guidelines
The requirement for CPT code 95921 Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function),
including 2 or more of the following heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio] is that at
least two of the tests should be performed in order to bill this code. If only one test is performed, modifier ‘52’ should be appended to indicate
that a reduced service was provided.
The requirement for CPT code 95922 Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic
adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of
passive tilt] is that both a passive tilt and the Valsalva maneuver be performed. If only one of the components is performed, then modifier 52,
reduced services, should be appended to code 95922.
CPT code 95924 should be reported only when both the parasympathetic function and vasomotor adrenergic function are tested together with
at least 5 minutes of passive tilt.
Definitions of the terms included in code descriptors:
Valsalva maneuver: Any forced expiratory effort (strain) against a closed airway, whether at the nose and mouth or at the glottis. This causes
high intrathoracic pressure that impedes venous return to the right atrium and, therefore, can be used to study cardiovascular effects of raised
peripheral venous pressure and decreased cardiac filling and cardiac output, as well as, post strain responses.
Valsalva ratio: The maximum heart rate divided by the lowest heart rate. The subject performs a standardized Valsalva maneuver, and the
derived heart rate is analyzed.
Quantitative sudomotor axon reflex test (QSART): An evaluation that uses a quantitative noninvasive method to determine the integrity of
the distal postganglionic sympathetic nerve fibers in diabetic and other neuropathies affecting autonomic nerves and in the progressive
autonomic disorders. It uses the stimulation of sympathetic nerve fibers to the sweat glands at standard sites. The test is done optimally on one
forearm site and three lower extremity sites in order to determine the severity and distribution of the sympathetic deficit. Coding Guidelines
Autonomic Function Tests Part A
Form Date: 09/18/09 Page 2 of 2 1-3.2.41 MP Part B FL Draft LCD
Revision History Date
03/24/2014
01/01/2013
01/23/2011
Revision
2- Removed reference to CPT code
95943 and revised language to CPT
code 95924. The effective date of this
revision is based on date of service.
1-Annual 2013 HCPCS Update. Added
CPT code 95924 and 95943 with
instructions. The effective date of this
revision is based on date of service.
Original
Local Coverage Article:
Autonomic function tests revision to the Part A LCD (A52786)
false
Contractor Information
Contractor Information Table
Contractor Name
First Coast Service Options, Inc.
false
Article Information
General Information
General Article Information Table
Article ID
A52786
Original Effective Date
Article Title
02/07/2014
Autonomic function tests revision to the Part A LCD
Revision Effective Date
AMA CPT / ADA CDT Copyright Statement
N/A
CPT only copyright 2002-2013 American Medical
Association. All Rights Reserved. CPT is a registered
Revision Ending Date
trademark of the American Medical Association.
N/A
Applicable FARS/DFARS Apply to Government Use.
Retirement Date
Fee schedules, relative value units, conversion
N/A
factors and/or related components are not assigned
by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly
or indirectly practice medicine or dispense medical
services. The AMA assumes no liability for data
contained or not contained herein. The Code on
Dental Procedures and Nomenclature (Code) is
published in Current Dental Terminology (CDT).
Copyright © American Dental Association. All rights
reserved. CDT and CDT-2010 are trademarks of the
American Dental Association.
Article Guidance
Article Text:
LCD ID number: L31465 (Florida/Puerto Rico/U.S. Virgin Islands)
Current Procedural Terminology® (CPT®) code 95943 was new for calendar year 2013 and at that time was
added to the autonomic function tests (AFT) local coverage determination (LCD) as a result of the Annual 2013
Healthcare Common Procedure Coding System (HCPCS) Update. It is described as an autonomic function test
for simultaneous, independent, quantitative measures of both parasympathetic and sympathetic function. It was
created to report when an autonomic function testing does not include beat-to-beat recording, or when testing
without the use of a tilt table. It was determined that the clinical validity and clinical utility of these technologies
have not been established and the qualifications of the personnel performing the testing are not standardized.
Therefore, CPT® code 95943 is being removed from the “ CPT®/HCPCS codes” section of the LCD, and
language is being added to the “Limitations” section of the LCD and the Coding Guidelines attachment
indicating it does not meet the medically reasonable and necessary threshold for coverage.
Additionally, CPT® code 95924 (AFT with passive tilt testing), also new for calendar year 2013, was also added
to the AFT LCD during the Annual 2013 HCPCS Update; however, the LCD does not specifically address this
code. Therefore, the LCD has been revised to include limited indications for this testing.
Effective date
This LCD revision is effective for services rendered on or after March 24, 2014. First Coast Service Options,
Inc. LCDs are available through the CMS Medicare coverage database at http://www.cms.gov/medicarecoverage-database/overview-and-quick-search.aspx external.gif.
Coding Guidelines for an LCD (when present) may be found by selecting “LCD Attachments” in the “Jump to
Section…” drop-down menu at the top of the LCD page.
false
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this
service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete
absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be
assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to
report this service. In most instances Revenue Codes are purely advisory; unless specified in the article
services reported under other Revenue Codes are equally subject to this coverage determination. Complete
absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article
should be assumed to apply equally to all Revenue Codes.
N/A
CPT/HCPCS Codes
N/A
Covered ICD-9 Codes
N/A
Non-Covered ICD-9 Codes
N/A
false
Revision History Information
N/A
false
Associated Documents
Related Local Coverage Document(s)
N/A
Related National Coverage Document(s)
N/A
Statutory Requirements URL(s)
N/A
Rules and Regulations URL(s)
N/A
CMS Manual Explanations URL(s)
N/A
Other URL(s)
N/A
Public Version(s)
Updated on 01/31/2014 with effective dates 02/07/2014 - N/A