L28996-LCD

Automated World Health

Local Coverage Determination (LCD) for Transesophageal Echocardiogram (L28996)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type MAC - Part A

LCD Information

Document Information

LCD ID Number L28996

LCD Title Transesophageal Echocardiogram

Contractor's Determination Number A93312

Primary Geographic Jurisdiction opens in 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 100-02, Medicare benefit Policy, Chapter 15, Section 80

CMS Manual System, Pub 100-03, Medicare National Coverage, Chapter 1, Section 220.5

CMS Manual System, Pub. 100-04, Medicare Claims Processing, Chapter 4, Section 4 and 20.2

Indications and Limitations of Coverage and/or Medical Necessity

Transesophageal Echocardiography (TEE) is a cardiac diagnostic procedure in which a modified endoscope, with an ultrasound transducer, is passed into the esophagus and/or stomach in order to obtain 2-D echo images and spectral and color doppler information about the heart and its great vessels.

Transesophageal Echocardiography (TEE) imaging is a viable alternative when transthoracic imaging is problematic or difficult. In many instances, abnormalities can be displayed that are missed with standard diagnostic techniques, and the images displayed are often of superior quality because of the high-resolution probes that can be used.

Medicare will consider transesophageal echocardiogram to be medically necessary in any of the following circumstances (see Covered ICD-9 Codes):

• Examination of prosthetic heart valves, primarily mitral

• Detection of:

- aortic dissection

- atrial septal defect

- congenital heart disease

- embolism or thrombosis, primarily involving left atrium

- intracardiac foreign bodies, tumors or masses

- mitral valve regurgitation

- vegetative endocarditis

• Intra-operative guide to left ventricular function

• Inadequacy of transthoracic echo due to:

- chest wall deformity, COPD

- open heart or chest surgery

- chest trauma

- obesity

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

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

93312 - ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

93313 - ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY

93314 - ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY

93315 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

93316 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY

93317 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY

93318 - ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS

C8925 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

C8926 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED C8926 BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT

C8927 - TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS

ICD-9 Codes that Support Medical Necessity

164.1 MALIGNANT NEOPLASM OF HEART

212.7 BENIGN NEOPLASM OF HEART

278.00 - 278.03 OBESITY UNSPECIFIED - OBESITY HYPOVENTILATION SYNDROME

391.0 - 391.9 ACUTE RHEUMATIC PERICARDITIS - ACUTE RHEUMATIC HEART DISEASE UNSPECIFIED

394.0 - 394.9 MITRAL STENOSIS - OTHER AND UNSPECIFIED MITRAL VALVE DISEASES

395.0 - 395.9 RHEUMATIC AORTIC STENOSIS - OTHER AND UNSPECIFIED RHEUMATIC AORTIC DISEASES

396.0 - 396.9 MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED

397.0 - 397.9 DISEASES OF TRICUSPID VALVE - RHEUMATIC DISEASES OF ENDOCARDIUM VALVE UNSPECIFIED

410.00 - 410.92 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.0 - 411.89 POSTMYOCARDIAL INFARCTION SYNDROME - OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER

414.00 - 414.07 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - 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

415.11 - 415.19 IATROGENIC PULMONARY EMBOLISM AND INFARCTION - OTHER PULMONARY EMBOLISM AND INFARCTION

421.0 - 421.9 ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS - ACUTE ENDOCARDITIS UNSPECIFIED

423.0 - 423.9 HEMOPERICARDIUM - UNSPECIFIED DISEASE OF PERICARDIUM

424.0 - 424.99 MITRAL VALVE DISORDERS - OTHER ENDOCARDITIS VALVE UNSPECIFIED

425.0 - 425.9 ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED

429.4 FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY

429.5 RUPTURE OF CHORDAE TENDINEAE

429.6 RUPTURE OF PAPILLARY MUSCLE

429.71 CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT

434.10 - 434.11 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION - CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION

441.00 - 441.03 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - DISSECTION OF AORTA THORACOABDOMINAL

444.01 - 444.9 SADDLE EMBOLUS OF ABDOMINAL AORTA - EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY

453.2 OTHER VENOUS EMBOLISM AND THROMBOSIS OF INFERIOR VENA CAVA

458.9 HYPOTENSION UNSPECIFIED

496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED

738.3 ACQUIRED DEFORMITY OF CHEST AND RIB

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 PATENT DUCTUS ARTERIOSUS

747.10 - 747.11 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) - INTERRUPTION OF AORTIC ARCH

747.31 - 747.39 PULMONARY ARTERY COARCTATION AND ATRESIA - OTHER ANOMALIES OF PULMONARY ARTERY AND PULMONARY CIRCULATION

754.81 - 754.89 PECTUS EXCAVATUM - OTHER SPECIFIED NONTERATOGENIC ANOMALIES

785.50 - 785.59 SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA

861.00 - 861.03 UNSPECIFIED INJURY OF HEART WITHOUT OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS WITHOUT OPEN WOUND INTO THORAX

861.10 - 861.13 UNSPECIFIED INJURY OF HEART WITH OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS AND OPEN WOUND INTO THORAX

996.2 MECHANICAL COMPLICATION DUE TO HEART VALVE PROSTHESIS

996.3 MECHANICAL COMPLICATION DUE TO CORONARY BYPASS GRAFT

996.61 INFECTION AND INFLAMMATORY REACTION DUE TO CARDIAC DEVICE IMPLANT AND GRAFT

996.71 OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS

996.72 OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT V42.1* HEART REPLACED BY TRANSPLANT

V42.2* HEART VALVE REPLACED BY TRANSPLANT

V43.3* HEART VALVE REPLACED BY OTHER MEANS

* According to the ICD-9-CM book, diagnosis codes V42.1, V42.2 and V43.3 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

Medical record documentation maintained by the ordering/referring physician must clearly indicate the medical necessity of transesophageal echocardiography studies covered by the Medicare program. Also, the results of transesophageal 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 transesophageal 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

Ferri, F (2004). Ferri’s BEST TEST. A Practical Guide to Clinical Laboratory Medicine and Diagnostic Imaging. Mosby’s Inc. Retrieved from http://www.home.mdconsult.com/das/book/body/0/1245/1.html on July 29, 2005.

Miller, R (2005). Miller’s Anesthesia sixth edition. Elsevier, Inc. Retrieved from http://www.home.mdconsult.com/das/book/body/0/01255/1.html on July 29, 2005.

Rakel, R; Bope, E (2005). CONN’s Current Therapy 2005. Elsevier, Inc. Retrieved from http://www.home.mdconsult.com/das/book/body/0/1261/1.html on July 29, 2005.

Zipes, D; Libby, P; Bonow, R (2005). Braunwald’s Heart Disease, A Textbook of Cardiovascular Medicine, 7th edition. Elsevier, Inc. Retrieved from http://www.home.mdconsult.com/das/book/body/0/1282/1.html on July 29,

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 10/01/2010

Revision History Number 3

Revision History Explanation Revision Number: 3 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. Deleted diagnosis codes 444.0 and 747.3. Added diagnosis codes 414.4, 444.01, and 747.31-747.39. The effective date of this revision is based on date of service.

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. Added ICD-9-CM code 278.03. 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:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Revised descriptor for diagnosis code 453.2. 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 (L28996) replaces LCD L1584 as the policy in notice. This document (L28996) 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 85 was changed

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

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change