L29000

 

TROPONIN

 

Indications and Limitations of Coverage and/or Medical Necessity

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

o 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).

o Patient presents with vague or atypical symptoms suggestive of a cardiac origin, which is not confirmed by an electrocardiogram.

o 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).

o 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.

o 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.

o 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.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

71x Clinic - Rural Health

85x 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 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED

410.01 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE

410.02 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

410.10 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED

410.11 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL INITIAL EPISODE OF CARE

410.12 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE

410.20 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED

410.21 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL INITIAL EPISODE OF CARE

410.22 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

410.30 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED

410.31 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL INITIAL EPISODE OF CARE

410.32 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE

410.40 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED

410.41 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL INITIAL EPISODE OF CARE

410.42 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE

410.50 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED

410.51 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL INITIAL EPISODE OF CARE

410.52 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE

410.60 TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED

410.61 TRUE POSTERIOR WALL INFARCTION INITIAL EPISODE OF CARE

410.62 TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE

410.70 SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED

410.71 SUBENDOCARDIAL INFARCTION INITIAL EPISODE OF CARE

410.72 SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE

410.80 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED

410.81 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES INITIAL EPISODE OF CARE

410.82 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE

410.90 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED

410.91 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE INITIAL EPISODE OF CARE

410.92 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.1 INTERMEDIATE CORONARY SYNDROME

413.0 ANGINA DECUBITUS

413.1 PRINZMETAL ANGINA

413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS

427.0 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

427.1 PAROXYSMAL VENTRICULAR TACHYCARDIA

427.2 PAROXYSMAL TACHYCARDIA UNSPECIFIED

427.31 ATRIAL FIBRILLATION

427.32 ATRIAL FLUTTER

427.41 VENTRICULAR FIBRILLATION

427.42 VENTRICULAR FLUTTER

427.5 CARDIAC ARREST

427.60 PREMATURE BEATS UNSPECIFIED

427.61 SUPRAVENTRICULAR PREMATURE BEATS

427.69 OTHER PREMATURE BEATS

427.81 SINOATRIAL NODE DYSFUNCTION

427.89 OTHER SPECIFIED CARDIAC DYSRHYTHMIAS

427.9 CARDIAC DYSRHYTHMIA UNSPECIFIED

729.5 PAIN IN LIMB

780.2 SYNCOPE AND COLLAPSE

780.8 GENERALIZED HYPERHIDROSIS

785.0 TACHYCARDIA UNSPECIFIED

786.03 APNEA

786.04 CHEYNE-STOKES RESPIRATION

786.05 SHORTNESS OF BREATH

786.06 TACHYPNEA

786.07 WHEEZING

786.09 RESPIRATORY ABNORMALITY OTHER

786.50 UNSPECIFIED CHEST PAIN

786.51 PRECORDIAL PAIN

786.52 PAINFUL RESPIRATION

786.59 OTHER CHEST PAIN

789.06 ABDOMINAL PAIN EPIGASTRIC

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

 

 

Documentation Requirements

 

• The medical records must document the medical necessity of the test including the test results.

o 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.

o The physician must state the clinical indication/medical necessity for the study in his order for the test.

o 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.

 

Treatment Logic:

• 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 are 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.

 

 

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.

 

FCSO LCD 2900, Troponin, 02/22/12. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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.

 

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT 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. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29000 TROPONIN