L28838

 

EXTERNAL COUNTERPULSATION (ECP)

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

• A full course of treatment usually consists of thirty-five (35) one-hour sessions, which may

o Be offered once or twice daily.

And

o Covers a period of four to seven weeks.

• Coverage beyond a full course of thirty-five (35) one-hour sessions should be rare.

• Patients are re-evaluated and if there is no angina class improvement after an initial thirty-five (35) hours of treatment, up to ten additional hours of treatment may be covered up until they improve by at least one angina class.

Re-treatment

• A repeat full course of treatment may be considered after one year, although this should represent a small percentage of patients.

• If within one year, after completion of the initial full course of thirty-five (35) hours of ECP, and the patient meets initial criteria and medical necessity for ECP, an additional course of treatment may be considered.

• Medicare will consider ECP medically reasonable and necessary when performed for dates of service on or after July 1, 1999 for patients with disabling stable angina that meet all the following criteria:

o Class III or Class IV angina based on the Canadian Cardiovascular Society Classification scale or an equivalent classification scale.

o Class III is characterized by marked limitation of ordinary physical activity, i.e., walking over two blocks on the level and climbing more than one flight in normal conditions.

 Less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain.

o Class IV is the inability to carry on any physical activity without discomfort-anginal syndrome may be present at rest.

 Symptoms of heart failure or the anginal syndrome may be present even at rest.

 If any physical activity is undertaken, discomfort is increased.

o A cardiologist or cardiothoracic surgeon must indicate that the patient is

 not amenable to surgical intervention, such as percutaneous transluminal coronary angioplasty (PTCA) or cardiac bypass because:

• Their condition is inoperable, or there is a high risk of operative complications or post-operative failure.

• Their coronary anatomy is not readily amenable to such procedures.

• They have co-morbid states which create excessive risk.

• This procedure must be performed under direct supervision of a physician. The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the personnel is performing the service.

• The use of hydraulic versions of these treatment devices is noncovered, and therefore will be denied.

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.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

 

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.

 

 

0480 Cardiology - General Classification

0940 Other Therapeutic Services - General Classification

 

 

CPT/HCPCS Codes

 

 

G0166 EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION

 

 

ICD-9 Codes that Support Medical Necessity

 

 

413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS

 

 

Documentation Requirements

• The medical record documentation maintained in the patient’s file must support that the service was ordered by the physician for a patient with Class III or Class IV angina not amenable to surgical intervention.

o In addition, the documentation must support that the service was performed and the type of equipment used.

o This information is usually found in the history and physical, progress notes, and/or hospital/office notes.

• The patient’s medical record must include:

o A patient profile that documents previous interventions and their effect in the treatment of angina.

o Patient’s medical history, symptoms, and risk factors.

o ECP record including the patient’s weight, vital signs before, during and after treatment.

o The effect of treatment on the angina, patient’s energy level, skin condition and duration of therapy.

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 thirty-five (35) one hour sessions, they may be subject to review for medical necessity.

Treatment Logic

• External counterpulsation (ECP), commonly referred to as enhanced external counterpulsation, is a non-invasive method of treatment for coronary artery disease refractory to medical and/or surgical therapy.

• ECP uses sequential diastolic inflation of lower extremity pneumatic cuffs to augment aortic diastolic pressure, increase venous return to the heart and decrease left ventricular afterload.

• Augmenting aortic diastolic pressure increases the coronary artery perfusion pressure and transmyocardial pressure gradient possibly enhancing coronary collateral development.

 

Sources of Information and Basis for Decision

 

Arora, R.R., Chow, T.M., Juin, D., Fleishman, B., Crawford, L., McKiernan, T., Nesto, R.W. (1999). The multicenter study of Enhanced external counterpulsation (MUST-EECP) effect of EECP on exercise – induced myocardial ischmeia and anginal episodes. Journal of American College of Cardiology, 33:1833-40. Abstract. This source was used to support indications and limitations for service.

 

Arora, R.R., Chow, T.M., Juin, D., Fleishman, B., Crawford, L., McKiernan, T., Nesto, R.W., Ferans, C.R., Keller, S. (2002). Effects of enhanced external coutnerpulsation on health related quality of life continue 12 months after treatment substudy of the Multicenter study of enhanced external counterpulsation. Journal Investigative Medicine, 50: 25-32. This source was used to support indications and limitations for service.

 

Michaels, A.D., Linemaien, G., Soran, O., Kelsey, S.F., Kennard, E.D. (2004). Two year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]). The American Journal of Cardiology (93) 4:453-458. This source was used to support indications and limitations for service.

 

EECP fact sheet. Vasomedical, Inc. World Wide Web.

 

FCSO LCD 29171, External Counterpulsation, 02/02/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Soran, O., Crawford, L., et al. (1999). Enhanced external counterpulsation in the management of patients with cardiovascular disease, Clinical Cardiology, 22, 173-178.

 

Suresh, K., Simandl, S., et al. (1998). Maximizing the hemodynamic benefit of enhanced external counterpulsation, Clinical Cardiology, 21, 649-653.

 

 

AMA CPT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

LCD EXTERNAL COUNTERPULSATION (ECP)