L29117-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Computed Tomographic Angiography

of the Chest, Heart and Coronary Arteries (L29117)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29117

LCD Title

Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries

Contractor's Determination Number 71275

Primary Geographic Jurisdiction opens in new window

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 02/02/2009

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. 100-08, Program Integrity Manual, Chapter 13, Section 5.1 (http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf

Indications and Limitations of Coverage and/or Medical Necessity

Multislice or Multidetector Computed Tomography (MDCT) angiography with its advanced spatial and temporal resolution has opened up new possibilities in the imaging of the major vessels of the chest, including aorta, pulmonary arteries, and coronary arteries.

MDCT technology for cardiac and coronary artery assessment requires thin (less than 1 mm) slices, 0.5 to 0.75 mm reconstructions, multiple simultaneous images (e.g. 40-64 or more slices) and cardiac gating (often requiring beta blockers for ideal heart rate). There is significant post processing, depending on the number of slices for image generation. For coronary artery imaging, the resulting images show a high correlation with stenotic lesions noted on diagnostic cardiac catheterization but more importantly, with atheromas on intracoronary ultrasound. Additionally, the technique may be helpful in defining the vascularity of chest or lung lesions.

Indications

Medicare will consider MDCT angiography of the chest for non-cardiac assessment (71275) medically reasonable and necessary for the following signs or symptoms of disease:

• Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;

• Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio-venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart;

• Assessment of suspected congenital anomalies of the heart or great vessels; and

• Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.

Medicare will consider MDCT angiography of the chest for cardiac assessment medically reasonable and necessary for the following signs or symptoms of disease:

• Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If a high pre-test probability of disease exists, as if the patient has known CAD, it is assumed the patient would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting could be performed at the same time).

• Assessment of suspected congenital anomalies of coronary circulation.

• Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging, if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary angiography would be done in addition to a subsequent coronary catheterization and angiogram).

• Evaluation of pulmonary veins prior to arrhythmia ablation procedures

• Evaluation of cardiac veins prior to insertion of biventricular pacemaker

Additionally, at times, it may be necessary to evaluate the patient for both cardiac and noncardiac disease. Pending the assignment of a code that more precisely describes this service, protocols using cardiovascular CT angiography for the evaluation of acute chest pain in the emergency setting, where pulmonary and/or aortic vascular etiology are also a concern, must be coded with CPT code 71275 only.

Billing CPT code 71275 plus one of the following CPT codes (75571, 75572, 75573, and 75574) would attest to the fact that two completely separate procedures were performed in their entirety.

Limitations

• The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.

• The test is never covered for patients with stable coronary artery disease without any significant change in signs or symptoms.

• The selection of the test should be made within the context of other testing modalities so that the resulting information facilitates the management decision, and does not merely add an additional layer of testing. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive calcification that would diminish the interpretive value.

• Coverage of this modality for coronary artery assessment is limited to devices that process thin, high-resolution slices (0.75 mm or less) A multidetector scanner must have a row of at least 32 detectors. For non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less.

• The administration of beta-blockers and/or other medications and the monitoring of the patient by a physician during the MDCT are not separately payable services.

• All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or qualified non- physician provider must be present during testing whenever cardioactive agents or contrast agents are administered (direct physician supervision). Ideally, this supervising physician will be experienced in this procedure and ACLS-certified.

• Electron Beam Technology provides high temporal resolution and enables quantitative assessment of the coronary artery calcium, but because of limited spatial resolution as a result of the limited z axis resolution (slice thickness=3.0 mm), it does not permit direct visualization in multi-reformation of the whole coronary system. Therefore, CT angiography of the heart is not considered medically necessary when performed with an EBT scanner.

Medicare expects a satisfactory level of competence from providers who submit claims for services rendered.” The CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 13, Section 5.1

(http://www.cms.hhs.gov/manuals/downloads/pim83c13.pdf outlines that “reasonable and necessary" services

are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.

The acceptable levels of competence, as defined by the American College of Cardiology ACC/American Heart Association (AHA) Clinical Competence Statement on cardiac imaging with Computed Tomography and Magnetic Resonance (2005) and the American College of Radiology (ACR) Clinical Statement on Noninvasive Cardiac Imaging (2005), are outlined as follows:

For the technical portion, a recommended level of competence is fulfilled when the image acquisition is obtained under all of the following conditions:

a. The service is performed by a radiologic technologist who is credentialed by a nationally recognized credentialing body (American Registry of Radiologic Technologists or equivalent) and meets state licensure requirements where applicable.

b. If intravenous beta blockers or nitrates are to be given prior to a CT coronary angiogram or calcium score, the test must be under the direct supervision of a certified registered nurse and physician (familiar with the administration of cardiac medications) who are able to respond to medical emergencies and it is strongly recommended that the certified register nurse and physician be ACLS certified.

c. When contrast studies are performed, the physician must provide direct supervision and the radiologic technologist or registered nurse administering the contrast must have appropriate training on the use and administration of contrast media.

For the professional portion, a recommended level of competence is fulfilled when the interpretation is performed by a physician meeting the following requirements:

a. The physician has appropriate additional training in CT Coronary Angiography and cardiac CT imaging equivalent to the guidelines set forth by the ACC or ACR (for example: the ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance (2005) and the ACR Clinical Statement on Noninvasive Cardiac Imaging (2005), or

b. The physician has appropriate medical staff privileges to interpret CT Coronary Angiograms at a hospital that participates in the Medicare program, and is actively training in cardiac CT (as in paragraph a). A grace period of 24 months should be allowed to acquire the necessary training.

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.

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.

99999 Not Applicable

CPT/HCPCS Codes

71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING

75571 COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST MATERIAL, WITH QUANTITATIVE EVALUATION OF CORONARY CALCIUM

COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC

75572 STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC 75573 STRUCTURE AND MORPHOLOGY IN THE SETTING OF CONGENITAL HEART DISEASE (INCLUDING 3D

IMAGE POSTPROCESSING, ASSESSMENT OF LV CARDIAC FUNCTION, RV STRUCTURE AND FUNCTION

AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART, CORONARY ARTERIES AND BYPASS GRAFTS (WHEN 75574 PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING (INCLUDING

EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY, ASSESSMENT OF CARDIAC FUNCTION, AND

EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)

ICD-9 Codes that Support Medical Necessity

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Further, these ICD-9-CM codes can be used only with the conditions listed in the Indications and Limitations sections of this LCD.

The following codes will be considered reasonable and necessary for CT Angiography of the chest for non-cardiac indications (CPT code 71275):

164.1 MALIGNANT NEOPLASM OF HEART

212.7 BENIGN NEOPLASM OF HEART

239.1 NEOPLASM OF UNSPECIFIED NATURE OF RESPIRATORY SYSTEM

337.9 UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM

415.0 - 415.19 ACUTE COR PULMONALE - OTHER PULMONARY EMBOLISM AND INFARCTION

416.0 - 416.9

417.0 - 417.9

PRIMARY PULMONARY HYPERTENSION - CHRONIC PULMONARY HEART DISEASE UNSPECIFIED

ARTERIOVENOUS FISTULA OF PULMONARY VESSELS - UNSPECIFIED DISEASE OF PULMONARY CIRCULATION

435.2 SUBCLAVIAN STEAL SYNDROME

441.1 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE

441.2 DISSECTION OF AORTA THORACIC

441.03 DISSECTION OF AORTA THORACOABDOMINAL

441.1 THORACIC ANEURYSM RUPTURED

441.2 THORACIC ANEURYSM WITHOUT RUPTURE

441.6 THORACOABDOMINAL ANEURYSM RUPTURED

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA

458.9 HYPOTENSION UNSPECIFIED

518.51 - 518.53 opens in new window

ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY - ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY

518.81 ACUTE RESPIRATORY FAILURE

518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

729.5 PAIN IN LIMB

729.81 SWELLING OF LIMB

747.10 - 747.11 opens in new window

747.20 - 747.29 opens in new window

747.31 - 747.39 opens in new window

747.40 - 747.49 opens in new window

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

CONGENITAL ANOMALY OF AORTA UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF AORTA

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

CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED - OTHER ANOMALIES OF GREAT VEINS

748.9 UNSPECIFIED CONGENITAL ANOMALY OF RESPIRATORY SYSTEM

785.0 TACHYCARDIA UNSPECIFIED

785.2 UNDIAGNOSED CARDIAC MURMURS

786.5 SHORTNESS OF BREATH

786.6 TACHYPNEA

786.09 RESPIRATORY ABNORMALITY OTHER

786.30 HEMOPTYSIS, UNSPECIFIED

786.39 OTHER HEMOPTYSIS

786.50 - 786.59 opens in

new window UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

786.6 SWELLING MASS OR LUMP IN CHEST

794.2 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM

The following codes will be considered reasonable and necessary for CT Angiography of the Chest for Cardiac indications for CPT codes 75571, 75572, 75573, 75574.

402.00 - 402.91

MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

411.1 INTERMEDIATE CORONARY SYNDROME

412 OLD MYOCARDIAL INFARCTION

413.0 - 413.9 opens in

new window ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

414.00 - 414.07 opens

in new window

Printed on 9/29/2012. Page 5 of 10

414.10 - 414.19

CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART

414.3 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE

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

420.0-420.99opensin ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE - OTHER ACUTE

745.0 - 745.9

PERICARDITIS COMMON TRUNCUS - UNSPECIFIED DEFECT OF SEPTAL CLOSURE

746.00-746.9opensin CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - UNSPECIFIED CONGENITAL

747.40 - 747.49

ANOMALY OF HEART

CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED - OTHER ANOMALIES OF GREAT VEINS

786.05 SHORTNESS OF BREATH

786.50 UNSPECIFIED CHEST PAIN

786.51 PRECORDIAL PAIN

786.59 OTHER CHEST PAIN

794.30 UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

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 documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, reason for the test, an interpretive report and copies of images. The computerized data with image reconstruction should also be maintained.

The medical record must contain documentation that fully supports the medical necessity of the procedure performed. This documentation includes, but is not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. This entire documentation- not just the test report or the finding /diagnosis on the order- must be available to Medicare upon request.

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

ACC/AHA Clinical Competence statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance (2005) Journal of the American College of Cardiology. 46 (2) 383-402.

ACR Practice Guideline for the performance and interpretation of CT angiography (CTA). American Medical Association. Clinical Examples in Radiology. 2 (1).

American Society of Cardiology Foundation. (2006). Task force 12: Training in Advanced Cardiovascular imaging (Computed Tomography). Journal of the American College of Cardiology. 47 (4).

Budoff, M., Achenbach, S., Duerinckx, A. (2003). Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography. Journal of the American College of Cardiology.42 (11): 1867- 78.

Funabashi, N., Kobayashi, Y., Perlroth, M., Rubin, G.D. (2003). Coronary artery: quantitative evaluation of normal diameter determined with electron-beam CT compared with cine coronary angiography-initial experience. Radiology. 226:263-271.

Giacomo, L., Cademartiri, F., Dake, M.D., Larini, P., Pavne, P. (2003). Value of three-dimensional reconstructions in evaluating thoracic aortic aneurysms. Images in Cardiovascular Medicine. 107:e34.

Gibbons, R.J., Eckel, R. H., & Jacobs, A. K. (2006). The utilization of cardiac imaging. Retrieved on April 11, 2006 from Circulation online at: http://www.circulatonaha.org.

Hoffman, M.H., Schmitz, B.L., Lieberknecht, M, Schulze, R., Ludwig, B., Kroschel, U., Jahnke, N., Haerer, W., Brambs, H., Aschoff, A.J. (2005). Noninvasive coronary angiography with multislice computed tomography. JAMA. 293: 2471-2478.

Kuettner, A., Schroeder, S., Feyer, A., Beck, T., Brueckner, A., Heuschmid, M., Burgstahler, C., Kopp, A., F., & Claussen, C.D. (2004). Noninvasive detection of coronary lesions using 16-detector multislice spiral computed tomography technology: initial clinical results. Journal of Amercian College of Cardiology, 44:1230-1237.

Model Local Coverage determination (LCD) workgroup for cardiac Computed Tomography and Computed Tomography Coronary Angiography (CTCA). (2005).

Mollet, N.R., Niemanm K., Lemos, P.A., Pattynama, P.M., Serruys, P.W., Krestin, G.P., deFeyter, P.J. (2004). Multislice spiral computed tomography coronary angiography in patients with stable angina pectoris. Journal of the American College of Cardiology. 43:2265-2270.

North Carolina LCD for Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries. Qaseem, A., Snow, V., Barry, P., Hornblake, E., Rodnick, J., Tobolic, T. & et al. (2007). Current diagnosis of

venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family

Physicians and the American College of Physicians. Annals of Family Medicine. 5, (1).

Sato, Y., Matsumoto, N., Kato, M., & et.al. (2003). Noninvasive assessment of coronary artery disease by multislice spiral computed tomography using a new retrospectively ECG-gated image reconstruction technique. Comparison with angiographic results. Circulation Journal. 401-405.

Schoenhagen, P., Halliburton, S.S., Stillman, A. E., Nissen, S.E., Tuzcu, E.,M., White, R.D. (2004). Noninvasive imaging of coronary arteries: Current and future role of Multi-detector row CT. Radiology. 2327-17.

Schoepf, U.J., Becker, C.R., Ohnesorge, B.M., Yucel, E.K. (2004). CT of coronary artery disease. Radiology.232: 18-37.

Singh, J. Houser, S., Heist, E., Ruskin, J. (2005). The coronary venous anatomy: a segmental approach. Journal of American College of Cardiology. 46 (1): 68-74.

Stein, P., Woodard, P., Weg, J., Wakefield, T., Tapson, V., Sostman, H. & et al. (2006). Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. The American Journal of Medicine. 119, 1048-1055.

Weinreb, J.C., Larson, P.A., Woodard, P.K., Stanford, W., Rubin, G.D., Stillman, A.E., Bluemke, D.A., Duerincks,

A. J., Dunnick, N.R., & Smith, G.C. (2005). American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging. Radiology, 235: 723-727.

White, R., Setser, R. (2002). Integrated approach to evaluating coronary artery. The American Journal of Cardiology. 10C:49-55.

Yamamuro, M., Tadamura, E., Kubo, S., Toyoda, H., Nishina, T., Ohba, M., Hosokawa, R., Kimura, T., Tamaki, N.,

Komedam M., Kita, T., & Konishi, J. (2005). Cardiac functional analysis with multi-detector row CT and segmented reconstruction algorithm: comparison with echocardiography, SPECT, and MR imaging. Radiology, 234: 381-390.

Yamamuro, M., Tadamura, E., Kubo, S. & et.al. (2005). Cardiac functional analysis with multi-detector row CT and segmental reconstruction algorithm: Comparison with echocardiography, spect, and MR imaging. Radiology. 234:381-390.

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 the advisory groups, which includes representatives from the Florida Society of

Cardiology, and the Florida Society of Radiology.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 4

Revision History Explanation Revision Number:4 Start Date of Comment Period:N/A

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

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Added diagnosis code 414.4 for CPT codes 75571, 75572, 75573 and 75574. Added diagnosis code ranges 518.51-518.53 and 747.31-747.39 for CPT code 71275. Deleted diagnosis codes 518.5 and 747.3 for CPT code 71275. The effective date of this revision is based on date of service.

Revision Number3

Start Date of Comment Period:N/A Start Date of Notice Period:07/01/2011 Revised Effective Date 06/14/2011

LCR B2011-076

June 2011 Connection

Explanation of Revision: Based on an outside request to clarify our current training statement outlined in this

LCD, language under the “Limitations” section of the LCD has been deleted and replaced with a revised statement regarding the qualification and training. Revisions will be effective based on process date.

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 B2010- 071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted diagnosis code 786.3 and replaced with diagnosis codes 786.30 and 786.39 and descriptor for CPT code 71275. 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:01/01/2010 Revised Effective Date:01/01/2010

LCR B2010-009

December 2009 Update

Explanation of Revision: Annual 2010 HCPCS Update. Added CPT codes 75571, 75572, 75573, 75574. Deleted CPT codes 0145T, 0146T, 0147T, 0148T, 0149T, 0150T, 0151T. Contractor Determination Number changed to 71275. 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:02/02/2009

LCR B2009-044FL

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29117) replaces LCD L23145 as the policy in notice. This document (L29117) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 11/15/2009 - CPT/HCPCS code 0145T was deleted from group 1

11/15/2009 - CPT/HCPCS code 0146T was deleted from group 1 11/15/2009 - CPT/HCPCS code 0147T was deleted from group 1 11/15/2009 - CPT/HCPCS code 0148T was deleted from group 1 11/15/2009 - CPT/HCPCS code 0149T was deleted from group 1 11/15/2009 - CPT/HCPCS code 0150T was deleted from group 1 11/15/2009 - CPT/HCPCS code 0151T was deleted from group 1

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

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:

71275 descriptor was changed in Group 1 75573 descriptor was changed in Group 1

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

Reason for Change