L28987-LCD

Automated World Health

Local Coverage Determination (LCD) for Stress Echocardiography (L28987)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28987

LCD Title Stress Echocardiography

Contractor's Determination Number A93350

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 10/01/2011 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 100-03, Medicare National Coverage, Chapter 1, Section 220.5

Indications and Limitations of Coverage and/or Medical Necessity

Echocardiography is used to image cardiac structures and function as well as flow direction and velocities within cardiac chambers and vessels. Usually these images are obtained from several positions on the chest wall and abdomen using a hand-held transducer.

Medicare has not previously published a specific policy concerning stress echocardiography. The purpose of this policy is to define the circumstances for which this service will be considered medically necessary by Medicare

Stress echocardiography will be considered medically reasonable and necessary and therefore covered by Medicare if any one of the following circumstances is present (see ICD-9 Codes that Support Medical Necessity):

• The patient has symptoms which require further investigation via stress testing and the patient has a significantly abnormal baseline EKG which would make interpretation of a standard exercise test (without imaging) inaccurate.

• The patient has abnormal or non-diagnostic standard exercise test and stress echocardiography is being performed to evaluate stress induced cardiac abnormality.

• The patient has symptoms which require further investigation by stress testing and the patient is on a medication (such as digoxin) which would interfere with the interpretation of a standard exercise test.

• The patient has a cardiac condition, such as mitral valve prolapse or other anatomic abnormality of the heart, which would interfere with the interpretation of a standard exercise stress test.

• The patient has confirmed coronary artery disease or congestive heart failure and stress echocardiography is necessary to evaluate the extent or significance of disease.

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 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

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.

0480 Cardiology - General Classification

CPT/HCPCS Codes

93350

ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES MMODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT;

93351

93352 USE OF ECHOCARDIOGRAPHIC CONTRAST AGENT DURING STRESS ECHOCARDIOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity

411.1 INTERMEDIATE CORONARY SYNDROME

411.81 - 411.89 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION - OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

412 OLD MYOCARDIAL INFARCTION 413.0 - 413.9 ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

414.1 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT

414.2 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY

414.3 CORONARY ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT

414.4 CORONARY ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT

414.6 CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART

414.7 CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

414.10 - 414.19 ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART

414.4 CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION

414.8 OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE

414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED

424.0 MITRAL VALVE DISORDERS

426.2 LEFT BUNDLE BRANCH HEMIBLOCK

426.3 OTHER LEFT BUNDLE BRANCH BLOCK

426.4 RIGHT BUNDLE BRANCH BLOCK

426.50 - 426.54 BUNDLE BRANCH BLOCK UNSPECIFIED - TRIFASCICULAR BLOCK

426.6 OTHER HEART BLOCK

426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION

427.31 ATRIAL FIBRILLATION

428.0 - 428.9 CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED

440.21 - 440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION - ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

960.7 POISONING BY ANTINEOPLASTIC ANTIBIOTICS

995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

E942.0* CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E942.1* CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V67.59 OTHER FOLLOW-UP EXAMINATION

* According to the ICD-9-CM book, diagnosis codes E942.0 and E942.1 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

General Information

Documentations Requirements

Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of echocardiography studies covered by the Medicare program. Also, the results of echocardiography studies covered by the Medicare program must be included in the patient's medical record. This information is normally found in the office/progress notes, hospital notes, and/or test results.

If the provider of echocardiography studies is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician's order for the studies.

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

American College of Cardiology Foundation (2003). ACC/AHA Clinical Competence Statement on Echocardiography. Journal of American College of Cardiology 41: 687-708. Retrieved from http://www.acc.org/clinical/competence/echo/VI_stress.htm on August 11, 2005.

AHA Scientific Statement (2003). ACC/AHA/ASE 2003 Guideline Update for the clinical Application of Echocardiography: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to update the 1997 guidelines for the clinical application of echocardiography). Journal of the American Society of Echocardiography 16 (10). Retrieved from http://www.home.mdconsult.com/das/article/body on August 11, 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 advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number 1

Revision History Explanation Revision Number: 1 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added diagnosis code 414.4. 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-

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 (L28987) replaces LCD L1484 as the policy in notice. This document (L28987) is effective on 02/16/2009.

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

8/1/2010 - The description for Revenue code 0480 was changed

Reason for Change