Local Coverage Determination (LCD) for Transthoracic Echocardiography (TTE) - 4C52AB-R11 (L26534) Contractor Information Contractor Name TrailBlazer Health Enterprises, LLC Back to Top LCD Information Document Information LCD ID Number L26534 LCD Title Transthoracic Echocardiography (TTE) - 4C52AB-R11 Contractor's Determination Number 4C-52AB AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to 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 Oversight Region Region IV Original Determination Effective Date For services performed on or after 03/01/2008 Original Determination Ending Date Revision Effective Date For services performed on or after 05/15/2012 Revision Ending Date 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. CMS National Coverage Policy This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for transthoracic echocardiography (TTE). Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for TTE and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies regarding TTE are found in the following Internet-Only Manuals (IOMs) published on the CMS Web site: • • • • Medicare Benefit Policy Manual – Pub. 100-02. Medicare National Coverage Determinations Manual – Pub. 100-03. Correct Coding Initiative – Medicare Contractor Beneficiary and Provider Communications Manual – Pub. 100-09, Chapter 5. Social Security Act (Title XVIII) Standard References, Sections: o o o o 1862(a)(1)(A) Medically Reasonable & Necessary. 1862(a)(1)(D) Investigational or Experimental. 1862(a)(7) Screening (Routine Physical Checkups). 1833(e) Incomplete Claim. Indications and Limitations of Coverage and/or Medical Necessity Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier (see “Coding Guidelines” section in the attached article for instructions). TTE affords unique insight into cardiac structure and function. It is a non-invasive technique in which pulsed high-frequency sound waves are used to visualize the contours, movements and dimensions of cardiac structures. Ultra-high frequency sound waves are directed toward and reflected by cardiovascular structures. Reflected echoes are translated into electrical impulses for display on a monitor and for recording and storage on either videotape or digital recording. The most commonly utilized echocardiographic techniques are motion-mode (M-mode) and two-dimensional (2-D) echocardiography. M-mode echocardiography employs a single pencil-like beam ultrasound view of cardiac structures. This method is especially useful for precisely recording the motion and dimensions of intracardiac structures with respect to time. Two-dimensional echocardiography employs an ultrasound beam rapidly swept through an arc, producing a cross-sectional or fan-shaped view of cardiac structures. It defines the configuration and changing dimensions of the chambers, dynamic cyclic variation in myocardial thickness and the associated valvular motions throughout the cardiac cycle. This technique is useful for recording lateral motion and providing the correct spatial relationship between cardiac structures. Doppler examination is a valuable adjunct to a complete echocardiographic examination. The basic principle utilizes the changes in frequency when a transmitted ultrasound wave is reflected from a moving surface, allowing measurement of velocity of movement (i.e., blood flow). Doppler velocity recordings (with volumetric flow calculations) provide an integrated picture of cardiac structure, function and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized. The rapid and non-invasive acquisition of this information has contributed to exponential application and to potential overutilization. This policy addresses the medically reasonable, necessary and appropriate application of TTE. Ventricular Function and Cardiomyopathies Changes in myocardial thickness (hypertrophy and thinning), derived parameters of contractility and in chamber volume and morphology can be quantified and charted over time by TTE. Cardiac responses to changes in volume, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional anomalies to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more-frequent-than-annual examinations. Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities. Hypertensive Cardiovascular Disease Left Ventricular Hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. In individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of LVH. TTE (CPT code 93308) may assist the decision to treat and the formulation of a treatment program. Baseline TTE (CPT code 93308) and periodic serial assessment (no more frequently than annually) would be medically appropriate. Acute Myocardial Infarction and Coronary Insufficiency TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. Absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six months and annually thereafter generally provides adequate supplemental data to a thoughtful clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment. The role for TTE in the emergency room assessment of individuals presenting with chest pain is in evolution. Absent supporting clinical findings of myocardial dysfunction, this application is considered investigational and will be subjected to medical necessity review. Exposure to Cardiotoxic Agents (Chemotherapeutic and External) Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered reasonably medically necessary. Cardiac Transplant and Rejection Monitoring TTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluation should focus on analysis of ventricular function and the integrity of valvular performance. TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid may alert to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight weeks following transplant with subsequent decremental frequency. Absent acute rejection episodes, approximately three TTE examinations are typically performed yearly in chronic transplant recipients. Native Valvular Heart Disease TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multivalve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist, especially interventions for mitral stenosis. Absent acute intervention or a discrete change in otherwise stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally, it is not medically reasonable and necessary to repeat these examinations more frequently than annually. Prosthetic Heart Valves (Mechanical and Bioprostheses) TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Reassessment following convalescence (three to six months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate. Acute Endocarditis TTE can provide diagnostic information. Larger vegetations can be directly visualized. Valvular anatomy and ventricular function may also be directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves. Pericardial Disease A collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually reasonable and medically necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids. Aortic Pathology TTE can provide valuable information when acute or chronic aortic pathology is present. However, the posterior window of TEE , coupled with the more posterior position of the thoracic aorta has rendered TEE a more determinative study. Non-invasive TTE remains the study of choice for following chronic aortic pathology when images suitable for serial quantitation can be obtained. Congenital Heart Disease In children and small adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and non-invasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation if the frequency exceeds an annual evaluation. Suspected Cardiac Thrombi and Embolic Sources TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial interstices and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias, especially atrial fibrillation, cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplemental therapeutic decisional data. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus, and the finding of thrombus or vegetation does not establish a cardiac embolic source. Absent the definition of and serial assessment for regression of potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions. Cardiac Tumors and Masses Infiltrative and ventricular tumors and masses can be visualized, their extent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, etc.), extensions and attachments. These acute pathologies are not typically followed serially. Critically Ill and Trauma Patients There is a role of echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion or a pericardial effusion may be confirmed. Pertubations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the exigencies of the clinical milieu. Ultrasonic equipment is increasingly more compact and portable. Certain highly portable (a.k.a. “hand-held”) scanners possess the same functional capabilities, hence, providing the same diagnostic value as traditional and larger “state of the art” instruments. Other scanners have limited capabilities in terms of providing a permanent record of the examination or reduced functional capability for performing a complete examination. Medicare will not cover studies performed in such a manner that the result constitutes a simple extension of the physical examination. To qualify for Medicare payment, a valid echocardiographic service must meet the following standards, regardless of the size of the instrument used to perform the study: • • • • • • Performed for an accepted clinical indication. Performed by a properly trained examiner. Provide a permanent record of images and findings. Provide sufficient information to support diagnostic conclusions in a manner that the results will not require confirmation by repeat examination either by a more qualified examiner or utilizing more sophisticated equipment. Provide a complete examination, including all of the services described by the CPT code billed. Include a written interpretation and report. Limitations: Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. As published in CMS IOM 100-08, Section 13.5.1, in order to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is: • • • Safe and effective. Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary). Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: o o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member. Furnished in a setting appropriate to the patient’s medical needs and condition. o o o Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient’s medical needs. At least as beneficial as an existing and available medically appropriate alternative. Back to Top 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 013x 018x 021x 022x 023x 071x 073x 077x 083x 085x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Hospital - Swing Beds Skilled Nursing - Inpatient (Including Medicare Part A) Skilled Nursing - Inpatient (Medicare Part B only) Skilled Nursing - Outpatient Clinic - Rural Health Clinic - Freestanding Clinic - Federally Qualified Health Center (FQHC) Ambulatory Surgery Center 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. Bill Type Note (above): Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010. Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Claims Processing Manual, for further guidance. 0480 0483 Cardiology - General Classification Cardiology - Echocardiology CPT/HCPCS Codes Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web. 93303 93304 93306 93307 93308 93320 93321 93325 93350 93351 C8929 C8930 Echo transthoracic Echo transthoracic Tte w/doppler complete Tte w/o doppler complete Tte f-up or lmtd Doppler echo exam heart Doppler echo exam heart Doppler color flow add-on Stress tte only Stress tte complete TTE w or wo fol wcon,Doppler TTE w or w/o contr, cont ECG ICD-9 Codes that Support Medical Necessity Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims. The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary. Medicare is establishing the following limited coverage for CPT/HCPCS codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930: Covered for: 074.1 074.20 074.23 086.0 088.81 093.0 093.1 093.20 093.24 EPIDEMIC PLEURODYNIA - COXSACKIE CARDITIS UNSPECIFIED - COXSACKIE MYOCARDITIS CHAGAS' DISEASE WITH HEART INVOLVEMENT LYME DISEASE ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC SYPHILITIC AORTITIS - SYPHILITIC ENDOCARDITIS OF VALVE UNSPECIFIED SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE 093.81 093.82 093.89 093.9 098.83 098.85 112.81 115.03 115.04 115.13 115.14 130.3 135 164.1 164.8 - SYPHILITIC PERICARDITIS - SYPHILITIC MYOCARDITIS OTHER SPECIFIED CARDIOVASCULAR SYPHILIS CARDIOVASCULAR SYPHILIS UNSPECIFIED - GONOCOCCAL PERICARDITIS - OTHER GONOCOCCAL HEART DISEASE CANDIDAL ENDOCARDITIS - HISTOPLASMA CAPSULATUM PERICARDITIS - HISTOPLASMA CAPSULATUM ENDOCARDITIS - HISTOPLASMA DUBOISII PERICARDITIS - HISTOPLASMA DUBOISII ENDOCARDITIS MYOCARDITIS DUE TO TOXOPLASMOSIS SARCOIDOSIS MALIGNANT NEOPLASM OF HEART MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED 198.89 SITES 212.7 BENIGN NEOPLASM OF HEART NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED 238.8 SITES - NEOPLASM OF UNCERTAIN BEHAVIOR SITE 238.9 UNSPECIFIED NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED 239.89 SITES 275.01 - HEREDITARY HEMOCHROMATOSIS - OTHER 275.03 HEMOCHROMATOSIS 275.09 OTHER DISORDERS OF IRON METABOLISM 276.0 - HYPEROSMOLALITY AND/OR HYPERNATREMIA - MIXED ACID276.4 BASE BALANCE DISORDER 276.50 VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA 276.52 276.69 OTHER FLUID OVERLOAD 276.7 - HYPERPOTASSEMIA - ELECTROLYTE AND FLUID DISORDERS 276.9 NOT ELSEWHERE CLASSIFIED 277.30 AMYLOIDOSIS, UNSPECIFIED 277.39 OTHER AMYLOIDOSIS 362.30 - RETINAL VASCULAR OCCLUSION UNSPECIFIED - VENOUS 362.37 ENGORGEMENT OF RETINA 368.00 AMBLYOPIA UNSPECIFIED 391.0 - ACUTE RHEUMATIC PERICARDITIS - ACUTE RHEUMATIC 391.2 MYOCARDITIS 391.8 - OTHER ACUTE RHEUMATIC HEART DISEASE - ACUTE 391.9 RHEUMATIC HEART DISEASE UNSPECIFIED 392.0 RHEUMATIC CHOREA WITH HEART INVOLVEMENT 393 CHRONIC RHEUMATIC PERICARDITIS 394.0 MITRAL STENOSIS - MITRAL STENOSIS WITH INSUFFICIENCY 394.2 394.9 OTHER AND UNSPECIFIED MITRAL VALVE DISEASES 395.0 - RHEUMATIC AORTIC STENOSIS - RHEUMATIC AORTIC 395.2 STENOSIS WITH INSUFFICIENCY 395.9 OTHER AND UNSPECIFIED RHEUMATIC AORTIC DISEASES MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS 396.0 MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE 396.3 INSUFFICIENCY 396.8 - MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES 396.9 MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED 397.0 - DISEASES OF TRICUSPID VALVE - RHEUMATIC DISEASES OF 397.1 PULMONARY VALVE RHEUMATIC DISEASES OF ENDOCARDIUM VALVE 397.9 UNSPECIFIED 398.0 RHEUMATIC MYOCARDITIS 398.90 - RHEUMATIC HEART DISEASE UNSPECIFIED - RHEUMATIC 398.91 HEART FAILURE (CONGESTIVE) 398.99 OTHER RHEUMATIC HEART DISEASES 401.0 - MALIGNANT ESSENTIAL HYPERTENSION - BENIGN 401.1 ESSENTIAL HYPERTENSION 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT 402.00 HEART FAILURE - MALIGNANT HYPERTENSIVE HEART 402.01 DISEASE WITH HEART FAILURE BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART 402.10 FAILURE - BENIGN HYPERTENSIVE HEART DISEASE WITH 402.11 HEART FAILURE UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT 402.90 HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART 402.91 DISEASE WITH HEART FAILURE HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE 403.00 IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY 403.01 DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH 403.10 CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR 403.11 UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, 403.90 403.91 404.00 404.03 404.10 404.13 405.01 405.09 405.11 405.19 405.91 405.99 410.00 410.02 410.10 410.12 410.20 410.22 410.30 410.32 BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC - KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE MALIGNANT RENOVASCULAR HYPERTENSION OTHER MALIGNANT SECONDARY HYPERTENSION BENIGN RENOVASCULAR HYPERTENSION OTHER BENIGN SECONDARY HYPERTENSION UNSPECIFIED RENOVASCULAR HYPERTENSION OTHER UNSPECIFIED SECONDARY HYPERTENSION ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL - EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR - WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL - EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR - WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL 410.40 - EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL 410.42 INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL 410.50 - EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL 410.52 INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE 410.60 UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION 410.62 SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE 410.70 UNSPECIFIED - SUBENDOCARDIAL INFARCTION 410.72 SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED 410.80 - SITES EPISODE OF CARE UNSPECIFIED - ACUTE 410.82 MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE 410.90 - EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL 410.92 INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 411.0 - POSTMYOCARDIAL INFARCTION SYNDROME - INTERMEDIATE 411.1 CORONARY SYNDROME ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL 411.81 INFARCTION OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART 411.89 DISEASE OTHER 412 OLD MYOCARDIAL INFARCTION 413.0 ANGINA DECUBITUS - PRINZMETAL ANGINA 413.1 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF 414.00 - VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS 414.07 OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART 414.10 - ANEURYSM OF HEART (WALL) - DISSECTION OF CORONARY 414.12 ARTERY 414.19 OTHER ANEURYSM OF HEART CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY 414.2 CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED 414.4 CORONARY LESION OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART 414.8 DISEASE - CHRONIC ISCHEMIC HEART DISEASE 414.9 UNSPECIFIED 415.0 ACUTE COR PULMONALE 415.11 - IATROGENIC PULMONARY EMBOLISM AND INFARCTION 415.13 SADDLE EMBOLUS OF PULMONARY ARTERY 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 416.0 - PRIMARY PULMONARY HYPERTENSION - CHRONIC 416.2 PULMONARY EMBOLISM 416.8 - OTHER CHRONIC PULMONARY HEART DISEASES - CHRONIC 416.9 PULMONARY HEART DISEASE UNSPECIFIED 417.0 - ARTERIOVENOUS FISTULA OF PULMONARY VESSELS 417.1 ANEURYSM OF PULMONARY ARTERY 417.8 - OTHER SPECIFIED DISEASES OF PULMONARY CIRCULATION UNSPECIFIED DISEASE OF PULMONARY CIRCULATION 417.9 420.0 ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE 420.90 - ACUTE PERICARDITIS UNSPECIFIED - ACUTE IDIOPATHIC 420.91 PERICARDITIS 420.99 OTHER ACUTE PERICARDITIS ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS - ACUTE 421.0 AND SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES 421.1 CLASSIFIED ELSEWHERE 421.9 ACUTE ENDOCARDITIS UNSPECIFIED 422.0 ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 422.90 ACUTE MYOCARDITIS UNSPECIFIED - TOXIC MYOCARDITIS 422.93 422.99 OTHER ACUTE MYOCARDITIS 423.0 HEMOPERICARDIUM - CARDIAC TAMPONADE 423.3 423.8 - OTHER SPECIFIED DISEASES OF PERICARDIUM 423.9 UNSPECIFIED DISEASE OF PERICARDIUM 424.0 MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS 424.3 424.90 - ENDOCARDITIS VALVE UNSPECIFIED UNSPECIFIED CAUSE 424.91 ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 424.99 OTHER ENDOCARDITIS VALVE UNSPECIFIED 425.0 ENDOMYOCARDIAL FIBROSIS 425.11 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY 425.18 OTHER HYPERTROPHIC CARDIOMYOPATHY 425.2 - OBSCURE CARDIOMYOPATHY OF AFRICA - SECONDARY 425.9 CARDIOMYOPATHY UNSPECIFIED 426.0 ATRIOVENTRICULAR BLOCK COMPLETE 426.10 - ATRIOVENTRICULAR BLOCK UNSPECIFIED - OTHER SECOND 426.13 DEGREE ATRIOVENTRICULAR BLOCK 426.2 - LEFT BUNDLE BRANCH HEMIBLOCK - RIGHT BUNDLE BRANCH BLOCK 426.4 426.50 - BUNDLE BRANCH BLOCK UNSPECIFIED - TRIFASCICULAR 426.54 BLOCK 426.6 - OTHER HEART BLOCK - ANOMALOUS ATRIOVENTRICULAR 426.7 EXCITATION 427.0 - PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA 427.2 PAROXYSMAL TACHYCARDIA UNSPECIFIED 427.31 ATRIAL FIBRILLATION - ATRIAL FLUTTER 427.32 427.41 VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER 427.42 427.5 CARDIAC ARREST 427.60 - PREMATURE BEATS UNSPECIFIED - SUPRAVENTRICULAR 427.61 PREMATURE BEATS 427.69 OTHER PREMATURE BEATS 427.81 SINOATRIAL NODE DYSFUNCTION 427.89 OTHER SPECIFIED CARDIAC DYSRHYTHMIAS 427.9 CARDIAC DYSRHYTHMIA UNSPECIFIED 428.0 - CONGESTIVE HEART FAILURE UNSPECIFIED - LEFT HEART 428.1 FAILURE 428.20 - UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON 428.23 CHRONIC SYSTOLIC HEART FAILURE 428.30 - UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON 428.33 CHRONIC DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART 428.40 FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND 428.43 DIASTOLIC HEART FAILURE 428.9 HEART FAILURE UNSPECIFIED 429.0 - MYOCARDITIS UNSPECIFIED - RUPTURE OF PAPILLARY 429.6 MUSCLE CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT 429.71 ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT 429.79 ELSEWHERE CLASSIFIED OTHER 429.81 - OTHER DISORDERS OF PAPILLARY MUSCLE - TAKOTSUBO 429.83 SYNDROME 429.89 429.9 431 434.00 434.01 434.10 434.11 OTHER ILL-DEFINED HEART DISEASES HEART DISEASE UNSPECIFIED INTRACEREBRAL HEMORRHAGE - CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION - CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT 434.90 CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION 434.91 UNSPECIFIED WITH CEREBRAL INFARCTION 435.0 - BASILAR ARTERY SYNDROME - VERTEBROBASILAR ARTERY 435.3 SYNDROME 435.8 - OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS 435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE 440.20 EXTREMITIES UNSPECIFIED - ATHEROSCLEROSIS OF NATIVE 440.24 ARTERIES OF THE EXTREMITIES WITH GANGRENE OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE 440.29 EXTREMITIES 441.00 - DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.1 - THORACIC ANEURYSM RUPTURED - THORACOABDOMINAL 441.7 ANEURYSM WITHOUT RUPTURE AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT 441.9 RUPTURE ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER 444.21 EXTREMITY - ARTERIAL EMBOLISM AND THROMBOSIS OF 444.22 LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY ACUTE FEBRILE MUCOCUTANEOUS LYMPH NODE SYNDROME 446.1 (MCLS) 446.7 TAKAYASU'S DISEASE OTHER VENOUS EMBOLISM AND THROMBOSIS OF INFERIOR 453.2 VENA CAVA 458.0 ORTHOSTATIC HYPOTENSION 458.9 HYPOTENSION UNSPECIFIED 518.4 ACUTE EDEMA OF LUNG UNSPECIFIED ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND 518.51 SURGERY - ACUTE AND CHRONIC RESPIRATORY FAILURE 518.53 FOLLOWING TRAUMA AND SURGERY 518.7 518.81 518.84 557.0 593.81 634.60 634.62 635.60 635.62 636.60 636.62 637.60 637.62 638.6 673.20 673.24 674.82 TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) - ACUTE RESPIRATORY FAILURE - ACUTE AND CHRONIC RESPIRATORY FAILURE ACUTE VASCULAR INSUFFICIENCY OF INTESTINE VASCULAR DISORDERS OF KIDNEY SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - SPONTANEOUS ABORTION COMPLETE COMPLICATED BY EMBOLISM LEGALLY INDUCED ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - LEGALLY INDUCED ABORTION COMPLETE COMPLICATED BY EMBOLISM ILLEGAL ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - ILLEGAL ABORTION COMPLETE COMPLICATED BY EMBOLISM LEGALLY UNSPECIFIED TYPE OF ABORTION UNSPECIFIED COMPLICATED BY EMBOLISM - LEGALLY UNSPECIFIED ABORTION COMPLETE COMPLICATED BY EMBOLISM FAILED ATTEMPTED ABORTION COMPLICATED BY EMBOLISM OBSTETRICAL BLOOD-CLOT EMBOLISM UNSPECIFIED AS TO EPISODE OF CARE - OBSTETRICAL BLOOD-CLOT EMBOLISM POSTPARTUM OTHER COMPLICATIONS OF PUERPERIUM WITH DELIVERY WITH POSTPARTUM COMPLICATION OTHER COMPLICATIONS OF PUERPERIUM 674.84 710.0 SYSTEMIC LUPUS ERYTHEMATOSUS - SYSTEMIC SCLEROSIS 710.1 745.0 COMMON TRUNCUS 745.10 - COMPLETE TRANSPOSITION OF GREAT VESSELS 745.12 CORRECTED TRANSPOSITION OF GREAT VESSELS 745.19 OTHER TRANSPOSITION OF GREAT VESSELS 745.2 - TETRALOGY OF FALLOT - OSTIUM SECUNDUM TYPE ATRIAL 745.5 SEPTAL DEFECT 745.60 - ENDOCARDIAL CUSHION DEFECT UNSPECIFIED TYPE 745.61 OSTIUM PRIMUM DEFECT 745.69 OTHER ENDOCARDIAL CUSHION DEFECTS 745.7 - COR BILOCULARE - UNSPECIFIED DEFECT OF SEPTAL 745.9 CLOSURE 746.00 CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED 746.01 - ATRESIA OF PULMONARY VALVE CONGENITAL - STENOSIS OF 746.02 PULMONARY VALVE CONGENITAL 746.09 OTHER CONGENITAL ANOMALIES OF PULMONARY VALVE 746.1 - TRICUSPID ATRESIA AND STENOSIS CONGENITAL 746.7 HYPOPLASTIC LEFT HEART SYNDROME 746.81 - SUBAORTIC STENOSIS CONGENITAL - CORONARY ARTERY 746.85 ANOMALY CONGENITAL 746.87 MALPOSITION OF HEART AND CARDIAC APEX 746.89 OTHER SPECIFIED CONGENITAL ANOMALIES OF HEART 746.9 UNSPECIFIED CONGENITAL ANOMALY OF HEART 747.0 PATENT DUCTUS ARTERIOSUS 747.10 - COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) 747.11 INTERRUPTION OF AORTIC ARCH 747.20 - CONGENITAL ANOMALY OF AORTA UNSPECIFIED 747.22 CONGENITAL ATRESIA AND STENOSIS OF AORTA 747.29 OTHER CONGENITAL ANOMALIES OF AORTA 747.31 - PULMONARY ARTERY COARCTATION AND ATRESIA 747.32 PULMONARY ARTERIOVENOUS MALFORMATION OTHER ANOMALIES OF PULMONARY ARTERY AND 747.39 PULMONARY CIRCULATION 747.40 - CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED 747.42 PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION 747.49 OTHER ANOMALIES OF GREAT VEINS 759.3 SITUS INVERSUS 759.82 MARFAN SYNDROME 780.02 TRANSIENT ALTERATION OF AWARENESS 780.2 SYNCOPE AND COLLAPSE 780.60 FEVER, UNSPECIFIED - POSTPROCEDURAL FEVER 780.62 782.5 CYANOSIS 785.0 - TACHYCARDIA UNSPECIFIED - OTHER ABNORMAL HEART 785.3 SOUNDS 785.50 SHOCK UNSPECIFIED - CARDIOGENIC SHOCK 785.51 785.59 OTHER SHOCK WITHOUT TRAUMA 786.05 SHORTNESS OF BREATH 786.09 RESPIRATORY ABNORMALITY OTHER 786.50 UNSPECIFIED CHEST PAIN - PRECORDIAL PAIN 786.51 786.59 OTHER CHEST PAIN 790.7 BACTEREMIA NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) 794.31 (EKG) 807.4 FLAIL CHEST UNSPECIFIED INJURY OF HEART WITHOUT OPEN WOUND 861.00 INTO THORAX - LACERATION OF HEART WITH PENETRATION 861.03 OF HEART CHAMBERS WITHOUT OPEN WOUND INTO THORAX UNSPECIFIED INJURY OF HEART WITH OPEN WOUND INTO 861.10 THORAX - LACERATION OF HEART WITH PENETRATION OF 861.13 HEART CHAMBERS AND OPEN WOUND INTO THORAX 901.0 - INJURY TO THORACIC AORTA - INJURY TO SUPERIOR VENA 901.2 CAVA 901.40 - INJURY TO PULMONARY VESSEL(S) UNSPECIFIED - INJURY 901.42 TO PULMONARY VEIN 922.1 CONTUSION OF CHEST WALL 958.0 - AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 958.1 FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 958.4 TRAUMATIC SHOCK 959.11 - OTHER INJURY OF CHEST WALL - OTHER INJURY OF 959.14 EXTERNAL GENITALS OTHER AND UNSPECIFIED INJURY OF OTHER SITES OF 959.19 TRUNK 960.7 POISONING BY ANTINEOPLASTIC ANTIBIOTICS 962.0 POISONING BY ADRENAL CORTICAL STEROIDS POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE 963.1 DRUGS 965.09 POISONING BY OTHER OPIATES AND RELATED NARCOTICS POISONING BY CARDIAC RHYTHM REGULATORS 972.0 POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF 972.1 SIMILAR ACTION 980.3 TOXIC EFFECT OF FUSEL OIL 986 TOXIC EFFECT OF CARBON MONOXIDE 990 EFFECTS OF RADIATION UNSPECIFIED 994.0 EFFECTS OF LIGHTNING ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC 994.8 CURRENT 995.1 ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED MECHANICAL COMPLICATION DUE TO CARDIAC PACEMAKER 996.01 (ELECTRODE) MECHANICAL COMPLICATION DUE TO HEART VALVE 996.02 PROSTHESIS - MECHANICAL COMPLICATION OF AUTOMATIC 996.04 IMPLANTABLE CARDIAC DEFIBRILLATOR INFECTION AND INFLAMMATORY REACTION DUE TO CARDIAC 996.61 DEVICE IMPLANT AND GRAFT 996.71 OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS 996.83 997.1 998.00 998.02 998.09 998.51 998.59 999.31 999.34 999.41 999.42 999.49 V12.53 V42.1 V42.2 V43.3 V58.69 V59.8 COMPLICATIONS OF TRANSPLANTED HEART CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED - POSTOPERATIVE SHOCK, UNSPECIFIED - POSTOPERATIVE SHOCK, SEPTIC POSTOPERATIVE SHOCK, OTHER INFECTED POSTOPERATIVE SEROMA OTHER POSTOPERATIVE INFECTION OTHER AND UNSPECIFIED INFECTION DUE TO CENTRAL - VENOUS CATHETER - ACUTE INFECTION FOLLOWING TRANSFUSION, INFUSION, OR INJECTION OF BLOOD AND BLOOD PRODUCTS ANAPHYLACTIC REACTION DUE TO ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS - ANAPHYLACTIC REACTION DUE TO VACCINATION ANAPHYLACTIC REACTION DUE TO OTHER SERUM PERSONAL HISTORY OF SUDDEN CARDIAC ARREST HEART REPLACED BY TRANSPLANT HEART VALVE REPLACED BY TRANSPLANT HEART VALVE REPLACED BY OTHER MEANS LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS DONORS OF OTHER SPECIFIED ORGAN OR TISSUE Medicare is establishing the following additional limited coverage for CPT/HCPCS codes 93303, 93304, 93306, 93307 and 93308: Covered for: V58.11* ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY Note: Use V58.11 to report baseline echocardiography for left ventricular assessment prior to initiating cancer treatment with a known cardiotoxic agent(s). Diagnoses that Support Medical Necessity N/A ICD-9 Codes that DO NOT Support Medical Necessity N/A ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD. Back to Top General Information Documentations Requirements • • • • • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. At a minimum, a complete study should include (2-D with or without M-mode) measurements of left ventricular end diastolic diameter, left ventricular end systolic diameter, left ventricular wall thickness, left atrial diameter, aortic valve excursion, qualitative description of left ventricular function, and, as applies, a description of any technical limitations for particular cases. Valid substitutes for the previous parameters may be recorded, such as LV volumes, ejection fraction and LV mass measurements. Doppler studies should indicate the modes utilized and give both qualitative and quantitative information where appropriate. The rationale for performing the study(s) must be clearly documented in or understood from the medical record. Medical records, including the permanent image, need not be submitted with the claim. However, these records must be furnished to Medicare upon request. Appendices N/A Utilization Guidelines Refer to the “Indications and Limitations of Coverage and/or Medical Necessity” section for utilization guidelines. Notice: This LCD imposes utilization guideline limitations. Despite Medicare allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. Sources of Information and Basis for Decision J4 (CO, NM, OK, TX) MAC Integration TrailBlazer adopted the Noridian Administrative Services, LLC LCD “Transthoracic Echocardiography (TTE),” for the Jurisdiction 4 (J4) MAC transition. Full disclosure of sources of information is found with original contractor LCD. Other Contractor Local Coverage Determinations “Echocardiography,” TrailBlazer LCD, (00400) L16396, (00900) L16328. “Transthoracic Echocardiography (TTE),” Noridian Administrative Services, LLC LCD, (CO) L14929. “Transthoracic Echocardiography (TTE),” Arkansas BlueCross BlueShield (Pinnacle) LCD, (NM, OK) L9767. “Stress Echocardiography,” Arkansas BlueCross BlueShield (Pinnacle) LCD, (NM, OK) L16191, L16192. Advisory Committee Meeting Notes Start Date of Comment Period End Date of Comment Period Start Date of Notice Period 12/20/2007 Revision History Number R11 Revision History Explanation R11 05/15/2012 Per provider request, added ICD-9-CM diagnosis code 453.2 in the “limited coverage” section of the LCD. Effective date: 05/15/2012. Updated AMA CPT/ADA CDT Copyright Statement. Effective date: 01/01/2012. R10 10/01/2011 Per CR 7454 (annual ICD-9-CM diagnosis code update) diagnosis codes 425.1, 518.5, 747.3, 998.0 and 999.4 were deleted and new diagnosis codes 414.4, 415.13, 425.11, 425.18, 518.51, 518.52, 518.53, 747.31, 747.32, 747.39, 998.00, 998.01, 998.02, 998.09, 999.32, 999.33, 999.34, 999.41, 999.42 and 999.49 were added for CPT/HCPCS codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930 in the “limited coverage” section of the LCD. Effective date: 10/01/2011. R9 07/01/2011 Per CR 7228, notice of automatic denial for claim line items with a GZ modifier added to definition of GZ modifier in “Coding Guidelines” section of related article. Effective date: 07/01/2011. R8 01/01/2011 Per CR 7121 (annual HCPCS update), description changed for the GA modifier in the article. Effective date: 01/01/2011. R7 10/18/2010 Use of LCD and related article made applicable to providers transitioning from WPS to TrailBlazer with addition of contractor number 04901. Effective date: dates of service on or after 10/18/2010. Per CR 7006 (Annual ICD-9-CM Diagnosis Coding Update), diagnosis codes 275.0 and 276.6 were deleted and added codes 275.01, 275.02, 275.03, 275.09 and 276.69 to limited coverage for codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930. Effective date: 10/01/2010. R6 12/21/2009 Per CR 6338, added end date of 03/31/2010 for TOB code 73X (no longer to be used for Medicare billing) and added TOB code 77X for use with dates of service on or after 04/01/2010 when billing for services rendered in a freestanding FQHC or a provider-based FQHC in the “Type of Bill Codes” section of the LCD and related article. Effective date: 01/04/2010. R5 10/01/2009 Per CR 6520 (Annual ICD-9-CM Diagnosis Coding Update), diagnosis code 239.8 replaced with diagnosis code 239.89 (Neoplasm of unspecified nature of other specified sites) and coverage expanded with addition of diagnosis code 416.2 to current range (416.0-416.1) in the “ICD-9-CM Codes That Support Medical Necessity” section of the LCD for HCPCS codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930. Effective date: 10/01/2009. R4 07/24/2009 Part A only: Per provider request, added revenue code 0483 to LCD and article. Effective dates: 03/01/2008 for New Mexico (Part B) and Oklahoma (Part A and Part B); 03/21/2008 for Colorado (Part B); and 06/13/2008 for Colorado (Part A), New Mexico (Part A) and Texas (Part A and Part B). R3 02/05/2009 Per provider request, ICD-9-CM diagnosis code V58.11 (encounter for antineoplastic chemotherapy and immunotherapy) added for use when baseline echocardiography (CPT/HCPCS codes 93303, 93304, 93306, 93307 and 93308) is required prior to initiating cancer treatment with cardiotoxic agents. Effective dates: March 1, 2008, for Oklahoma (Parts A and B) and New Mexico (Part B); March 21, 2008, for Colorado (Part B); and June 13, 2008, for Colorado (Part A), New Mexico (Part A) and Texas (Part A and Part B). R2 12/15/2008 Per CR 6236, added new CPT codes 93306, 93351, C8929 and C8930 to the LCD and article. Added these codes to the existing limited coverage in the LCD. Effective date: 01/01/2009. R1 10/01/2008 Per CR 6107 (Annual ICD–9–CM Diagnosis Coding Update): Added diagnosis codes 414.3, 780.60, 780.61 and 780.62, and removed 780.6; these changes were made to the limited coverage for CPT codes 93303, 93304, 93307, 93308, 93320, 93321, 93325 and 93350. Effective date: 10/01/2008. 06/13/2008 LCD effective in TX Part A and Part B and Part A CO and NM 06/13/2008. 03/21/2008 LCD effective in CO Part B 03/21/2008. 03/01/2008 LCD effective in NM Part B and OK Part A and Part B 03/01/2008. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update. Reason for Change ICD9 Addition/Deletion Related Documents This LCD has no Related Documents. LCD Attachments Article 4C-52AB-R11 TTE Transthorac Back to Top All Versions Updated on 05/18/2012 with effective dates 05/15/2012 - N/A Updated on 10/14/2011 with effective dates 10/01/2011 - 05/14/2012 Updated on 10/06/2011 with effective dates 10/01/2011 - N/A Updated on 08/19/2011 with effective dates 07/01/2011 - 09/30/2011 Updated on 07/27/2011 with effective dates 01/01/2011 - 06/30/2011 Updated on 02/08/2011 with effective dates 01/01/2011 - N/A Updated on 11/21/2010 with effective dates 10/18/2010 - 12/31/2010 Updated on 11/16/2010 with effective dates 10/18/2010 - N/A Updated on 09/08/2010 with effective dates 09/09/2010 - 10/17/2010 Updated on 08/01/2010 with effective dates 12/21/2009 - 09/08/2010 Updated on 08/01/2010 with effective dates 12/21/2009 - N/A Updated on 03/17/2010 with effective dates 12/21/2009 - N/A Updated on 03/07/2010 with effective dates 12/21/2009 - N/A Updated on 12/21/2009 with effective dates 12/21/2009 - N/A Updated on 12/21/2009 with effective dates 12/21/2009 - N/A Some older versions have been archived. Please visit the MCD Archive Site to retrieve them. Read the LCD Disclaimer Back to Top Footer Links Get Help with File Formats and Plug-Ins • • • Submit Feedback Department of Health & Human Services • Medicare.gov • USA.gov • Web Policies & Important Links • Privacy Policy • Freedom of Information Act • No Fear Act Centers for Medicare & Medicaid Services, 7500 Security Boulevard Baltimore, MD 21244 13 Article Title Transthoracic Echocardiography (TTE) – 4C-52AB-R11 Contractor’s Determination Number 4C-52AB Contractor Name TrailBlazer Health Enterprises Contractor Number • • 04001 (04101, 04201, 04301, 04401, 04901). 04002 (04102, 04202, 04302, 04402). Contractor Type • • MAC – Part A. MAC – Part B. AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to 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 contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright (c) American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. Primary Geographic Jurisdiction • • • • CO. NM. OK. TX: • Indian Health Service. End Stage Renal Disease (ESRD) facilities. Skilled Nursing Facilities (SNFs). Rural Health Clinics (RHCs). Transitioned WPS legacy providers. o o o o Oversight Region • • Region IV. Region VI. Original Article Effective Date 03/01/2008 03/21/2008 06/13/2008 Article Revision Effective Date 05/15/2012 Article Ending Effective Date N/A Article Text Abstract Transthoracic Echocardiography (TTE) affords unique insight into cardiac structure and function. M-mode echocardiography employs a single pencil-like beam ultrasound view of cardiac structures. This method is especially useful for precisely recording the motion and dimensions of intracardiac structures with respect to time. Two-dimensional imaging (2-D) defines the configuration and changing dimensions of the chambers, dynamic cyclic variation in myocardial thickness and the associated valvular motions throughout the cardiac cycle. Superimposition of Doppler velocity recordings (with volumetric flow calculations) provides an integrated picture of cardiac structure, function and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized. The rapid and non-invasive acquisition of this information has contributed to exponential application and to potential overutilization. This LCD addresses the medically reasonable, necessary and appropriate application of TTE. Part A Program Instructions: Reasons for Denial • • • • • All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD. Service(s) rendered is (are) not consistent with accepted standards of medical practice. The medical record does not verify that the service described by the CPT/HCPCS code was provided. The service does not follow the guidelines of the related LCD. The service is considered: o Investigational. o For routine screening. o A program exclusion. o Otherwise not covered. o Never medically necessary. Coding Guidelines • • • Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits. Do not report intraoperative echocardiographic monitoring using echocardiography codes included in this policy. For an echocardiogram study that does not produce a permanent image or is performed with equipment that is not fully capable of performing all of the services of a CPT code listed in this LCD, report CPT code 93799© (cardiovascular procedure) and describe on the claim the specific echocardiographic service performed. “Not fully capable” means that the echocardiographic equipment does not produce all the images and/or data regarding anatomy and blood flow characteristics required for the service as defined by the CPT code and description billed. Fully functional modalities include continuous wave Doppler, pulsed-wave Doppler, duplex image, color • • • • • • • • • flow velocity mapping or imaging, M-mode, 2-D real time B-mode, analysis of bi-directional blood flow, ECG referencing, spectral analysis and harmonic imaging. CPT codes specify required modalities. Studies not meeting minimal requirements of a complete study should be considered to be limited or follow-up studies. Use ICD-9-CM code V58.69 when performing a baseline TTE prior to administration of a high-risk, cardiotoxic medication. Procedure codes C8929, C8930, 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350 and 93351 shall be reported with Revenue Code 480. Refer to the Correct Coding Initiative for “bundling” information. Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service. To report these services, use the appropriate HCPCS or CPT code(s). All coverage criteria must be met before Medicare can reimburse this service. When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered. o Modifiers: GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.) GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.) GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. See also Bill Type and Revenue Code sections below. Part B Program Instructions: Reasons for Denial • • • • All other indications not listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the related LCD. Service(s) rendered is (are) not consistent with accepted standards of medical practice. The medical record does not verify that the service described by the CPT/HCPCS code was provided. The service does not follow the guidelines of the related LCD. • The service is considered: o Investigational. o For routine screening. o A program exclusion. o Otherwise not covered. o Never medically necessary. Coding Guidelines • • • • • • • • • • Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. Provisions of this LCD do not take precedence over CCI edits. Do not report intraoperative echocardiographic monitoring using echocardiography codes included in this policy. For an echocardiogram study that does not produce a permanent image or is performed with equipment that is not fully capable of performing all of the services of a CPT code listed in this LCD, report CPT code 93799© (cardiovascular procedure) and describe on the claim the specific echocardiographic service performed. “Not fully capable” means that the echocardiographic equipment does not produce all the images and/or data regarding anatomy and blood flow characteristics required for the service as defined by the CPT code and description billed. Fully functional modalities include continuous wave Doppler, pulsed-wave Doppler, duplex image, color flow velocity mapping or imaging, M-mode, 2-D real time B-mode, analysis of bi-directional blood flow, ECG referencing, spectral analysis and harmonic imaging. CPT codes specify required modalities. Studies not meeting minimal requirements of a complete study should be considered to be limited or follow-up studies. Use ICD-9-CM code V58.69 when performing a baseline TTE prior to administration of a high-risk, cardiotoxic medication. Refer to the Correct Coding Initiative for “bundling” information. Diagnosis(es) must be present on any claim submitted and coded to the highest level of specificity for that date of service. To report these services, use the appropriate HCPCS or CPT code(s). All coverage criteria must be met before Medicare can reimburse this service. When billing for this service in a non-covered situation (e.g., does not meet indications of the related LCD), use the appropriate modifier (see below). To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered. o Modifiers: GA: Waiver of liability statement issued as required by payer policy, individual case. (Use for patients who do not meet the covered indications and limitations of this LCD and for whom an ABN is on file.) (ABN does not have to be submitted but must be made available upon request.) GZ: Item or service expected to be denied as not reasonable and necessary. (Use for patients who do not meet the covered indications and limitations of this LCD and who did not sign an ABN and the provider expects the item/service to be denied. All claim line items submitted with the GZ modifier will be denied automatically and will not be subject to complex medical review.) GY: Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Bill Type and Revenue Codes below DO NOT apply to Part B. • 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. 12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 83X, 85X Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010. 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. Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance. 0480, 0483 CPT/HCPCS Codes Note:Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors C8929 C8930 93303© 93304© 93306© 93307© 93308© 93320© 93321© 93325© 93350© 93351© in policies published on the Web. TTE w or wo fol w con, Doppler (OPPS) TTE w or w/o contr, cont ECG (OPPS) Echo transthoracic Echo transthoracic Tte w/doppler, complete Echo exam of heart Echo exam of heart Doppler echo exam, heart Doppler echo exam, heart Doppler color flow add-on Echo transthoracic Stress tte complete Other Comments N/A