Local Coverage Determination (LCD) for
Transthoracic Echocardiography (TTE) - 4C52AB-R11 (L26534)
Contractor Information
Contractor Name
TrailBlazer Health
Enterprises, LLC
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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
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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
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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.
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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.
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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
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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
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them.
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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
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CO.
NM.
OK.
TX:
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Indian Health Service.
End Stage Renal Disease (ESRD) facilities.
Skilled Nursing Facilities (SNFs).
Rural Health Clinics (RHCs).
Transitioned WPS legacy providers.
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Oversight Region
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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
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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
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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
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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
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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.
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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.
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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