L28833-LCD

Automated World Health

Local Coverage Determination (LCD) for Electrocardiography (L28833)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28833

LCD Title Electrocardiography

Contractor's Determination Number A93000

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

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 © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2010 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.3

CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Section 20.15

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

An electrocardiogram (EKG) is a graphic representation of electrical activity within the heart. Electrodes placed on the body in predetermined locations sense this electrical activity, which is then recorded by various means for review and interpretation. EKG recordings are used to diagnose a wide range of heart disease and other conditions that manifest themselves by abnormal cardiac electrical activity.

EKG services are covered diagnostic tests when there are documented signs and symptoms or other clinical indications for providing the service. Coverage includes the review and interpretation of EKG’s only by a physician. There is no coverage for EKG services when rendered as a screening test or as part of a routine examination unless performed as part of the one-time, “Welcome to Medicare” preventive physical examination under section 611 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003.

Electrocardiograms are indicated for diagnosis and patient management purposes involving symptoms of the heart, pericardium, thoracic cavity, and systemic diseases which produce cardiac abnormalities.

Medicare will consider an EKG medically necessary in any of the following circumstances:

1. Initial diagnostic workup for a patient that presents with complaints of symptoms such as chest pain, palpitations, dyspnea, dizziness, syncope, etc. which may suggest a cardiac origin.

2. Evaluation of a patient on a cardiac medication for a cardiac arrhythmia or other cardiac condition which affects the electrical conduction system of the heart ( e.g., inotropics such as digoxin; antiarrhythmics such as Tambocor, Procainamide, or Quinidine; and antianginals such as Cardizem, Isordil, Corgard, Procardia, Inderal and Verapamil). The EKG is necessary to evaluate the effect of the cardiac medication on the patient’s cardiac rhythm and/or conduction system.

3. Evaluation of a patient with a pacemaker with or without clinical findings (history or physical examination) that suggest possible pacemaker malfunction.

4. Evaluation of a patient who has a significant cardiac arrhythmia or conduction disorder in which an EKG is necessary as part of the evaluation and management of the patient. These disorders may include, but are not limited to, the following: Complete Heart Block, Second Degree AV Block, Left Bundle Branch Block, Right Bundle Branch Block, Paroxysmal VT, Atrial Fib/Flutter, Ventricular Fib/Flutter, Cardiac Arrest, Frequent PVCs, Frequent PACs, Wandering Atrial Pacemaker, and any other unspecified cardiac arrhythmia.

5. Evaluation of a patient with known Coronary Artery Disease (CAD) and/or heart muscle disease that presents with symptoms such as increasing shortness of breath (SOB), palpitations, angina, etc.

6. Evaluation of a patient’s response to a newly established therapy for angina, palpitations, arrhythmias, SOB or other cardiopulmonary disease process.

7. Evaluation of patients after coronary artery revascularization by Coronary Artery Bypass Grafting (CABGs), Percutaneous Transluminal Coronary Angiography (PTCA), thrombolytic therapy (e.g., TPA, Streptokinase, Urokinase), and/or stent placement.

8. Evaluation of patients presenting with symptoms of a Myocardial Infarction (MI).

9. Evaluation of other symptomatology which may indicate a cardiac origin especially in those patients who have a history of an MI, CABG surgery or PTCA or patients who are being treated medically after a positive stress test or cardiac catherization.

10. Pre-operative Evaluation of the patient when:

- undergoing cardiac surgery such as CABGs, automatic implantable cardiac defibrillator, or pacemaker, or

- the patient has a medical condition associated with a significant risk of serious cardiac arrhythmia and/or myocardial ischemia such as Diabetes, history of MI, angina pectoris, aneurysm of heart wall, chronic ischemic heart disease, pericarditis, valvular disease or cardiomyopathy to name a few.

11. Evaluation of a patient’s response to the administration of an agent known to result in cardiac or EKG abnormalities (for patients with suspected, or at increased risk of developing, cardiovascular disease or dysfunction). Examples of these agents are antineoplastic drugs, lithium, tranquilizers, anticonvulsants, and antidepressant agents.

12. When performed as a baseline evaluation prior to the initiation of an agent known to result in cardiac or EKG abnormalities. An example of such an agent is verapamil.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0730 EKG/ECG (Electrocardiogram) - General Classification

CPT/HCPCS Codes

93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT

93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT

93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY

ICD-9 Codes that Support Medical Necessity

079.0 - 079.99 ADENOVIRUS INFECTION IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE - UNSPECIFIED VIRAL INFECTION

240.0 - 246.9 GOITER SPECIFIED AS SIMPLE - UNSPECIFIED DISORDER OF THYROID

250.00 - 250.93 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED

276.1 HYPEROSMOLALITY AND/OR HYPERNATREMIA

276.2 HYPOSMOLALITY AND/OR HYPONATREMIA

276.3 ACIDOSIS

276.4 ALKALOSIS

276.5 MIXED ACID-BASE BALANCE DISORDER

276.50 - 276.52 VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA

276.69 OTHER FLUID OVERLOAD

276.7 HYPERPOTASSEMIA

276.8 HYPOPOTASSEMIA

276.9 ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED

277.00 - 277.09 CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS - CYSTIC FIBROSIS WITH OTHER MANIFESTATIONS

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

337.1 IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY, UNSPECIFIED

337.2 CAROTID SINUS SYNDROME

337.09 OTHER IDIOPATHIC PERIPHERAL AUTONOMIC NEUROPATHY

337.9 UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM

390 - 392.9 RHEUMATIC FEVER WITHOUT HEART INVOLVEMENT - RHEUMATIC CHOREA WITHOUT HEART INVOLVEMENT

393 - 398.99 CHRONIC RHEUMATIC PERICARDITIS - OTHER RHEUMATIC HEART DISEASES

401.0 - 405.99 MALIGNANT ESSENTIAL HYPERTENSION - OTHER UNSPECIFIED SECONDARY HYPERTENSION

410.00 - 414.9 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

415.0 - 417.9ACUTE COR PULMONALE - UNSPECIFIED DISEASE OF PULMONARY CIRCULATION

420.0 - 429.9 ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE - HEART DISEASE UNSPECIFIED

435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

440.0 - 448.9 ATHEROSCLEROSIS OF AORTA - OTHER AND UNSPECIFIED CAPILLARY DISEASES

668.10 - 668.14 CARDIAC COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY UNSPECIFIED AS TO EPISODE OF CARE - CARDIAC COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY POSTPARTUM

710.0 - 710.9 SYSTEMIC LUPUS ERYTHEMATOSUS - UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE

714.0 - 714.9 RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

745.0 - 745.9 COMMON TRUNCUS - UNSPECIFIED DEFECT OF SEPTAL CLOSURE

746.00 - 746.9 CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - UNSPECIFIED CONGENITAL ANOMALY OF HEART

747.0 - 747.9 PATENT DUCTUS ARTERIOSUS - UNSPECIFIED CONGENITAL ANOMALY OF CIRCULATORY SYSTEM

780.02 TRANSIENT ALTERATION OF AWARENESS

780.2 SYNCOPE AND COLLAPSE

780.31 - 780.39 FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS

780.4 DIZZINESS AND GIDDINESS

780.79 OTHER MALAISE AND FATIGUE

782.0 DISTURBANCE OF SKIN SENSATION

782.61 - 782.62 PALLOR - FLUSHING

785.1 TACHYCARDIA UNSPECIFIED

785.2 PALPITATIONS

785.3 UNDIAGNOSED CARDIAC MURMURS

785.4 OTHER ABNORMAL HEART SOUNDS

785.50 - 785.59 SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA

786.00 - 786.09 RESPIRATORY ABNORMALITY UNSPECIFIED - RESPIRATORY ABNORMALITY OTHER

786.50 - 786.59 UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

786.6 SWELLING MASS OR LUMP IN CHEST

789.1 ABDOMINAL PAIN RIGHT UPPER QUADRANT

789.2 ABDOMINAL PAIN LEFT UPPER QUADRANT

789.06 ABDOMINAL PAIN EPIGASTRIC

794.30 - 794.39 UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM - OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM

799.01 - 799.02 ASPHYXIA - HYPOXEMIA

799.1 RESPIRATORY ARREST

860.0 - 860.5 TRAUMATIC PNEUMOTHORAX WITHOUT OPEN WOUND INTO THORAX - TRAUMATIC PNEUMOHEMOTHORAX WITH OPEN WOUND INTO THORAX

861.00 - 861.32 UNSPECIFIED INJURY OF HEART WITHOUT OPEN WOUND INTO THORAX - LACERATION OF LUNG WITH OPEN WOUND INTO THORAX

959.11 - 959.19 OTHER INJURY OF CHEST WALL - OTHER AND UNSPECIFIED INJURY OF OTHER SITES OF TRUNK

972.0 - 972.9 POISONING BY CARDIAC RHYTHM REGULATORS - POISONING BY OTHER AND UNSPECIFIED AGENTS PRIMARILY AFFECTING THE CARDIOVASCULAR SYSTEM

980.0 - 989.9 TOXIC EFFECT OF ETHYL ALCOHOL - TOXIC EFFECT OF UNSPECIFIED SUBSTANCE CHIEFLY NONMEDICINAL AS TO SOURCE

995.0 - 995.94 OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE CLASSIFIED - SYSTEMIC INFLAMMATORY RESPONSE SYNDROME DUE TO NONINFECTIOUS PROCESS WITH ACUTE ORGAN DYSFUNCTION

996.00 - 996.09 MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT - OTHER MECHANICAL COMPLICATION OF CARDIAC DEVICE IMPLANT AND GRAFT

996.80 - 996.89 COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN

997.1 CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED

997.2 PERIPHERAL VASCULAR COMPLICATIONS NOT ELSEWHERE CLASSIFIED

997.39 OTHER RESPIRATORY COMPLICATIONS

E933.1* ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E936.0* OXAZOLIDINE DERIVATIVES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E936.1* HYDANTOIN DERIVATIVES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E936.2* SUCCINIMIDES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E936.3* OTHER AND UNSPECIFIED ANTICONVULSANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E939.0 - E939.9* NTIDEPRESSANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - UNSPECIFIED PSYCHOTROPIC AGENT CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V45.01* CARDIAC PACEMAKER IN SITU

V45.02* AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR IN SITU V45.09* OTHER SPECIFIED CARDIAC DEVICE IN SITU

V45.81* POSTSURGICAL AORTOCORONARY BYPASS STATUS

V45.82* PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V58.83 ENCOUNTER FOR THERAPEUTIC DRUG MONITORING

V72.81 PRE-OPERATIVE CARDIOVASCULAR EXAMINATION

* According to the ICD-9-CM book, diagnosis codes E933.1, E936.0-E936.3, E939.0-E939.9, V45.01, V45.02, V45.09, V45.81, V45.82 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.

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 N/A

General Information

Documentations Requirements

In order to be covered and reimbursed by Medicare, a service must meet several requirements. It must fall within a defined benefit category, it cannot be excluded from coverage, either by statute or policy, and it must be medically necessary. Section 1862(a)(1)(a) of the Social Security Act precludes program payment for services not deemed to be medically necessary. This section of the Act underpins all Medicare regulations. Any document issued by CMS or any of its contractors, which contains statements regarding criteria for coverage and payment

of any service (office visits, procedures, diagnostic tests, etc.) has as an underlying assumption that the service must comply with the requirements of §1862(a)(1)(a). The law states that the test cannot be reimbursed if it is not medically reasonable and necessary. As a consequence, it is incumbent upon the providers to be sure the service they provide is medically necessary, even in the instance where the documentation that proves medical necessity is created and/or housed by an entity other than the performing provider.

It is also important to recognize that medical necessity is not met simply by merely matching a procedure code to a diagnosis code, as may be listed in a policy. In the case of a diagnostic test, it may be medically necessary in some instances but not in others; or it may be medically necessary at some point in the treatment of the beneficiary but not at others. Otherwise stated, it is not enough to only link a procedure code to a correct, payable diagnosis code – the test must be appropriate and medically necessary at the time and point at which it

is being performed in the course of the patient’s evaluation. Furthermore, the Code of Federal Regulations (CFR), Title 42, part 410.32, specifies that all diagnostic tests must be ordered by a provider who is the treating provider for the patient and who will use the test results in the patient’s care. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

Like with any service reimbursed by Medicare, to support medical necessity there must be documentation in the medical record as to why a certain modality was chosen/performed. This entire documentation – not just the test report or the finding/diagnosis on the order – must be available for review in order to establish medical reasonableness and necessity by Medicare’s criteria.

The EKG strip and a copy of the test results should be maintained in the medical record. In addition, the medical record must support that the physician interpreted and agrees with the test results and show that the results are being used to manage the patient.

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in the order

for the test.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Hurst, J.W. (2003). Current status of clinical electrocardiography with suggestions for the improvement of the interpretive process. The American Journal of Cardiology, 92, 1072-1079.

Lee, T.H. (2001). Electrocardiography: ACC/AHA guidelines summary. In Braunwald: Heart Disease: A Textbook of Cardiovascular Medicine, Vol. 101, No. 101.

U.S. Preventative Services Task Force (2004). Screening for Coronary Heart Disease: Recommendation statement. (Annals of internal medicine, Volume 40 No. 7). Retrieved from www.anals.org on June 3, 2005.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the advisory groups, which includes representatives from the Florida Chapter of the American College of Cardiology.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR A2010-050

September 2010 Bulletin

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted diagnosis code range 276.0-276.9 and replaced with individual diagnosis codes 276.0, 276.1, 276.2, 276.3, 276.4, 276.50-276.52, 276.69 (new code), 276.7,

276.8 and 276.9. New diagnosis code 276.61 was not added to the LCD in that code range. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:08/01/2009 Revised Effective Date: 07/09/2009

LCR A2009-067

July 2009 Bulletin

Explanation of Revision: Documentation requirements were revised to further clarify requirements that physicians must document their interpretation of test results and how they are used in the management of the patient. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-034FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28833) replaces LCD L1132 as the policy in notice. This document (L28833) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 8/1/2010 - The description for Bill Type Code 12 was changed

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 75 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0730 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

93000 descriptor was changed in Group 1 93005 descriptor was changed in Group 1

Reason for Change