L29000-LCD

Automated World Health

Local Coverage Determination (LCD) for Troponin (L29000)

Contractor Information

Contractor Name

First Coast Service Options, Inc

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L29000

LCD Title Troponin

Contractor's Determination Number A84484

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

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 © 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 02/22/2012

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Troponin is a muscle protein that attaches to both actin and tropomyosin. It is concerned with calcium binding and inhibiting cross-bridge formation. Troponin is a complex of three proteins: troponin C, troponin I, and troponin T. The distribution of these isoforms varies between cardiac muscle and slow- and fast-twitch skeletal muscle. Their importance lies in the fact that the isoforms troponin I and troponin T show a high degree of cardiac specificity, and therefore, have an important role in the diagnostic evaluation of a patient presenting with symptoms suggestive of a cardiac origin.

Cardiac Troponin I (cTnI) is highly specific for myocardial tissue, is thirteen times more abundant in the myocardium than CK-MB on a weight basis, is not detectable in the blood of healthy persons, shows a greater proportional increase above the upper limit of the reference interval in patients with myocardial infarction and remains elevated for seven to ten days after an episode of myocardial necrosis. In addition, measurements of cTnI is useful to clarify which increases in CK-MB are due to myocardial injury and which ones reflect acute or chronic skeletal muscle abnormalities.

Troponin T, the tropomyosin-binding protein of the regulatory complex located on the contractile apparatus of cardiac myocytes, is also a sensitive and specific marker for myocardial necrosis. Damaged heart muscle releases the protein, troponin T, which increases in the bloodstream as early as 3 hours after the onset of chest pain and remains at an elevated level for 2 to 7 days.

Troponin levels are considered medically reasonable and necessary to rule out myocardial injury only under the following conditions:

• patient presents with signs and symptoms of an acute myocardial infarction (prolonged chest pain often described as squeezing, choking, stabbing, etc., usually spreading across chest to the left arm; dyspnea, diaphoresis) which is confirmed by an electrocardiogram (EKG, ECG);

• patient presents with vague or atypical symptoms suggestive of a cardiac origin, which is not confirmed by an electrocardiogram;

• patient evaluation reveals a normal creatine kinase MB isoenzyme (CK-MB), however, the EKG demonstrates new changes consistent with ischemia (e.g., flipped T waves, ST-segment depression); or

• to distinguish patients with unstable angina from those with a non-Q wave myocardial infarction.

Initially, it is expected that a qualitative Troponin level (procedure code 84512) is performed on a patient with suspected myocardial injury. If the results of the qualitative Troponin level is positive, then the quantitative level of Troponin I or Troponin T (procedure code 84484) is performed, usually with the same blood specimen, to determine if the symptoms are cardiac in nature. The Troponin C isoform is not useful in the management of myocardial infarction and it is not necessary to monitor both the T and I isoform.

The quantitative test is normally performed every 8-12 hours the first 24 hours. Once the determination is made whether myocardial injury has occurred, it is expected that a Troponin level will be performed only when the results are to be used in the active treatment of the patient.

Also, it is not necessary to use Troponin in addition to Creatine Kinase (procedure codes 82550-82554) in the management of patients with myocardial infarction.

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

021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

071x Clinic - Rural Health 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.

0301 Laboratory - Chemistry

CPT/HCPCS Codes

84484 TROPONIN, QUANTITATIVE

84512 TROPONIN, QUALITATIVE

ICD-9 Codes that Support Medical Necessity

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

411.1 INTERMEDIATE CORONARY SYNDROME

413.0 - 413.9 ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

427.0 - 427.9 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - CARDIAC DYSRHYTHMIA UNSPECIFIED

729.5 PAIN IN LIMB

780.2 SYNCOPE AND COLLAPSE

780.8 GENERALIZED HYPERHIDROSIS

785.0 TACHYCARDIA UNSPECIFIED

786.3 APNEA

786.4 CHEYNE-STOKES RESPIRATION

786.5 SHORTNESS OF BREATH

786.6 TACHYPNEA

786.7 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

786.50 - 786.59 opens

in new window UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

789.06 ABDOMINAL PAIN EPIGASTRIC

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

Any ICD-9-CM code that does not appear under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

The medical records must document the medical necessity of the test including the test results. This information is usually found in the office/progress notes, emergency/hospital notes, and/or laboratory results.

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 his order for the test. If the test is performed for the patient with vague or atypical symptoms, e.g., epigastric pain,

syncope, the rationale for why this symptom may be cardiac related should be documented.

Appendices

Utilization Guidelines N/A

Sources of Information and Basis for Decision

ACC/AHA 2002 Guideline Update for the Management of Patients with Unstable Angina and non-ST segment Elevation Myocardial Infarction. American College of Cardiology and American Heart Association.

Henrikson, CA (et al) (2004) Prognostic usefulness of marginal troponin t elevation. American Journal of Cardiology, 93: 275-279. This source used to help define patients who would benefit from the use of troponin levels as a diagnostic tool.

Lai, CS (et al) (2004) Prevalence of troponin-t elevation during out-of-hospital cardiac arrest. American Journal of Cardiology, 93:754-756. This source used to help define the medical necessity of using troponin levels as a diagnostic tool and to determine if there is a limited timeframe when it may be useful in treating the patient.

Landesberg, G (et al) (2005) Myocardial ischemia, cardiac troponin, and the long-term survival of high-cardiac risk critically ill intensive care unit patients. Critical Care Medicine 33: 6. This source used to understand the role and efficacy of the troponin level in treatment of critically ill patients.

Lee, T. H., & Goldman, L. (2000). Evaluation of the patient with acute chest pain. The New England Journal of Medicine, 342 (16), 1187-1195.

Wiviott, SD., & Braunwald, E (2004) Unstable angina and non-st-segment elevation myocardial infarction: part I. Initial evaluation and management , and hospital care. American Family Physician 70: 3. This source used to understand the role of troponin levels in the treatment of less critically ill patients.

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:01/01/2012 Revised Effective Date: 02/22/2012

LCR A2012-023

March 2012 Connection

Explanation of revision: LCD revised under the ‘ICD-9 Codes that Support Medical Necessity’ section of the LCD to add ICD-9-CM diagnosis code 780.8. The effective date of this revision is based on process date.

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 (L29000) replaces LCD L1577 as the policy in notice. This document (L29000) 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 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 71 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0301 was changed

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:

84484 descriptor was changed in Group 1 84512 descriptor was changed in Group 1

Reason for Change ICD9 Addition/Deletion