L29296-LCD

Automated World Health

Local Coverage Determination (LCD) for Transthoracic Echocardiography (TTE) (L29296)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29296

LCD Title Transthoracic Echocardiography (TTE)

Contractor's Determination Number 93303

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 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/16/2011 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 Determinations, Chapter 1, Section 220.5 Program Memorandum, Transmittal AB-02-085 (CR 2194)

Program Memorandum, Transmittal AB-03-091 (CR 2763)

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.5

Indications and Limitations of Coverage and/or Medical Necessity

Echocardiography is an ultrasonic examination of the heart. It is a widely used noninvasive technology to assess cardiac anatomy and function. A Doppler examination is a valuable adjunct to a complete echocardiographic examination, and allows for the evaluation of the presence and severity of valvular stenosis, valvular regurgitation, and ventricular dysfunction of cardiac output, intracardiac pressures and intracardiac shunts.

This local coverage determination (LCD) addresses the medical necessity and appropriate application of transthoracic echocardiography (TTE). Echocardiography is indicated in the evaluation of derangements of valvular, myocardial and pericardial function. The general applications for coverage can be summarized by the following clinical settings:

1. Native Valvular Heart Disease

Detection of mitral stenosis was among the first practical clinical applications of Transthoracic Echocardiography (TTE). TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of valvular pathologies can be quantified.

Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist. For example, Noninvasive TTE remains the study of choice for monitoring chronic aortic pathology and other valvular lesions when images suitable for serial quantitation can be obtained. In the absence of acute intervention or a change in stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally, it is not medically reasonable and necessary to repeat these examinations more frequently than annually.

2. Prosthetic Heart Valves (Mechanical and Bio-prostheses)

TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Subsequent studies are appropriate when clinical signs or symptoms suggest prosthetic valve malfunction, or when the natural history of the implanted prosthesis suggest a high risk of developing prosthetic malfunction. TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Reassessment following convalescence (three to six months) is appropriate. Thereafter, with the absence defined clinical events or obvious change in physical examination findings, an annual stability

assessment is considered medically reasonable and necessary.

3. Endocarditis

TTE can provide diagnostic information. Larger vegetations may be directly visualized, while valvular anatomy and ventricular function directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Examination frequency in the acute phase of illness is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be determined by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves. Thereafter, absent defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and necessary.

4. Ventricular Function and Cardiomyopathies

Changes in myocardial thickness (hypertrophy and thinning), chamber volume and morphology as well as derived parameters of contractility can be quantified and charted over time by TTE. Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the

relative contributions of myocardial and valvular functional perturbations to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. There is increasing data to support the prognostic value of diastolic function parameters in patients with systolic dysfunction. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more-frequent-than-annual examinations.

5. Acute Myocardial Infarction and Coronary Insufficiency

TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, utilization frequency will typically be dictated by the acute clinical course. The role for

TTE in the emergency room assessment of individuals who present with chest pain is in evolution. This application may be used as part of a detailed clinical evaluation, especially as a triage for patients with chest pain syndrome. If absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six months and annually thereafter generally provides adequate supplemental data for a clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment.

6. Hypertensive Cardiovascular Disease

Left ventricular hypertrophy correlates with prognosis in hypertensive cardiovascular disease. Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of left ventricular hypertrophy and /or left ventricular mass calculation. TTE (CPT code 93308) may assist the decision to treat and the formulation of a treatment program. Baseline TTE (CPT code 93308) and periodic assessment (no more frequently than annually) would be medically reasonable and necessary.

7. Cardiac Transplant and Rejection Monitoring

TTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluations focus on analysis of ventricular function and the integrity of valvular performance. TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid may alert to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. TTE is performed weekly for the first four to eight weeks following transplant with subsequent decreasing frequency. In the absence of an acute rejection episode, approximately three TTE examinations are typically performed yearly in chronic transplant recipients.

8. Exposure to Cardiotoxic Agents (Chemotherapeutic and External)

Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. When echocardiography is used to monitor cardiac toxicity of chemotherapeutic agents, an initial complete TTE may be performed prior to first administration of the agent. Also, bimonthly TTE during therapy and follow up TTE at six months following therapy are generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent of an abrupt change in clinical signs and/or symptoms, annual assessment would be considered medically reasonable and necessary.

9. Pericardial Disease

Detection and quantitation of the amount of pericardial effusion were among the first and remain an important application of TTE. Pericardial fluid accumulations of as little as twenty (20) milliliters have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. A collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows. The acute clinical status will dictate examination frequency. TTE and Doppler techniques are quite helpful in identifying pericardial constriction and differentiating it from restrictive myocardial disease.

Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually considered medically reasonable and necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids.

10. Congenital Heart Disease

In children and young adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and noninvasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation if the frequency exceeds an annual evaluation.

11. Cardiac Tumors and Masses

Infiltrative and ventricular tumors and masses can be visualized, their extent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. Transesophageal echocardiography (TEE) provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, etc.) extensions and attachments. These acute pathologies are not typically followed serially.

12. Critically Ill and Trauma Patients

There is a role for echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspected aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Perturbations of volume status may be more completely defined and management strategies modified.

13. Suspected Cardiac Thrombi and Embolic Sources

TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial appendages and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias such as atrial fibrillation, cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplemental therapeutic decisional data. In those instances where the precise diagnosis and localization of potentially embolic material is of paramount therapeutic importance and the information so obtained will potentially and substantively alter therapy, or the risk of anticoagulants is inordinately high, consideration should be given to TEE. Absent the definition of a serial assessment for regression of potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions.

14. Contrast echocardiography

Contrast echocardiography is indicated when a conventional study has failed to provide adequate and critically needed information on left ventricular function. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient.

15. Diseases of Aorta

TTE can be of great value in demonstrating aneurismal enlargement of the ascending and descending portions of the thoracic aorta, in detecting aortic dissection, and in evaluating the size of the aorta in patients with aortic valve diseases or certain conditions associated with aortic pathology (i.e., Marfan’s syndrome or connective tissue disorders). Aortic coarctions can also be demonstrated when clinical features suggest this entity.

Limitations

Echocardiographic studies that are not reasonable and necessary to obtain clinically significant diagnostic or monitoring information are not indicated. The carrier will utilize the American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines (Class III) indications as a reference for such determinations.

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

93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE

93304 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY

93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M- MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY

93307 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M- MODE RECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLER ECHOCARDIOGRAPHY

93308 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M- MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY

93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE

93321 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING)

93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY)

ICD-9 Codes that Support Medical Necessity

For Procedure codes 93306, 93307 and 93308 (with or without Doppler)

038.0 STREPTOCOCCAL SEPTICEMIA

38.10 STAPHYLOCOCCAL SEPTICEMIA UNSPECIFIED

38.11 METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AUREUS SEPTICEMIA

38.12 METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS SEPTICEMIA

038.19 OTHER STAPHYLOCOCCAL SEPTICEMIA

38.2 PNEUMOCOCCAL SEPTICEMIA

38.3 SEPTICEMIA DUE TO ANAEROBES

38.40 - 038.49 SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISM UNSPECIFIED - OTHER SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISMS

38.8 OTHER SPECIFIED SEPTICEMIAS

38.9 UNSPECIFIED SEPTICEMIA

74.21 COXSACKIE PERICARDITIS

74.22 COXSACKIE ENDOCARDITIS

74.23 COXSACKIE MYOCARDITIS

86.0 CHAGAS' DISEASE WITH HEART INVOLVEMENT

88.81 LYME DISEASE

93.1 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC

93.2 SYPHILITIC AORTITIS

93.20 - 93.24 SYPHILITIC ENDOCARDITIS OF VALVE UNSPECIFIED - SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE

93.81 SYPHILITIC PERICARDITIS

93.82 SYPHILITIC MYOCARDITIS

098.84 GONOCOCCAL ENDOCARDITIS

112.81 CANDIDAL ENDOCARDITIS

115.3 HISTOPLASMA CAPSULATUM PERICARDITIS

115.4 HISTOPLASMA CAPSULATUM ENDOCARDITIS

115.13 HISTOPLASMA DUBOISII PERICARDITIS

115.14 HISTOPLASMA DUBOISII ENDOCARDITIS

130.3 MYOCARDITIS DUE TO TOXOPLASMOSIS

135 SARCOIDOSIS

164.1 MALIGNANT NEOPLASM OF HEART

212.7 BENIGN NEOPLASM OF HEART

275.01 - 275.09 HEREDITARY HEMOCHROMATOSIS - OTHER DISORDERS OF IRON METABOLISM

276.50 VOLUME DEPLETION, UNSPECIFIED

276.51 DEHYDRATION

276.52 HYPOVOLEMIA

277.30 AMYLOIDOSIS, UNSPECIFIED

277.39 OTHER AMYLOIDOSIS

324.0 - 324.1 INTRACRANIAL ABSCESS - INTRASPINAL ABSCESS

362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION

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

392.0 RHEUMATIC CHOREA WITH HEART INVOLVEMENT

393 CHRONIC RHEUMATIC PERICARDITIS

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

398.0 - 398.99 RHEUMATIC MYOCARDITIS - OTHER RHEUMATIC HEART DISEASES

401.0 MALIGNANT ESSENTIAL HYPERTENSION

402.00 - 402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.10 - 402.11 BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.90 - 402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

404.00 - 404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

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

412 OLD MYOCARDIAL INFARCTION

413.0 - 413.9 ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

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 ANEURYSM OF HEART (WALL)

414.11 ANEURYSM OF CORONARY VESSELS

414.12 DISSECTION OF CORONARY ARTERY

414.19 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

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

416.0 - 416.9 PRIMARY PULMONARY HYPERTENSION - CHRONIC PULMONARY HEART DISEASE UNSPECIFIED

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

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

422.0 ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE

422.90 ACUTE MYOCARDITIS UNSPECIFIED

422.91 IDIOPATHIC MYOCARDITIS

422.92 SEPTIC MYOCARDITIS

422.93 TOXIC MYOCARDITIS

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

426.0 ATRIOVENTRICULAR BLOCK COMPLETE

426.12 MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK

426.3 OTHER LEFT BUNDLE BRANCH BLOCK

426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION

426.82 LONG QT SYNDROME

426.9 CONDUCTION DISORDER UNSPECIFIED

427.1 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

427.2 PAROXYSMAL VENTRICULAR TACHYCARDIA

427.3 PAROXYSMAL TACHYCARDIA UNSPECIFIED

427.31 - 427.32 ATRIAL FIBRILLATION - ATRIAL FLUTTER

427.41 - 427.42 VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER

427.5 CARDIAC ARREST

427.60 - 427.69 PREMATURE BEATS UNSPECIFIED - OTHER PREMATURE BEATS

427.81 - 427.89 SINOATRIAL NODE DYSFUNCTION - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS

427.9 CARDIAC DYSRHYTHMIA UNSPECIFIED

428.1 CONGESTIVE HEART FAILURE UNSPECIFIED

428.2 LEFT HEART FAILURE

428.20 - 428.23 UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE

428.30 - 428.33 UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE

428.40 - 428.43 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE

428.9 HEART FAILURE UNSPECIFIED

429.1 MYOCARDITIS UNSPECIFIED

429.2 MYOCARDIAL DEGENERATION

429.3 CARDIOMEGALY

429.4 FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY

429.5 RUPTURE OF CHORDAE TENDINEAE

429.6 RUPTURE OF PAPILLARY MUSCLE

429.71 - 429.79 CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT - CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED OTHER

429.81 - 429.89 OTHER DISORDERS OF PAPILLARY MUSCLE - OTHER ILL-DEFINED HEART DISEASES

429.9 HEART DISEASE UNSPECIFIED

434.00 - 434.91 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION

UNSPECIFIED WITH CEREBRAL INFARCTION

435.0 - 435.9 BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA

436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE

440.0 ATHEROSCLEROSIS OF AORTA

441.00 - 441.9 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE

442.0 - 442.9 ANEURYSM OF ARTERY OF UPPER EXTREMITY - OTHER ANEURYSM OF UNSPECIFIED SITE

443.1 RAYNAUD'S SYNDROME

443.2 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)

443.21 - 443.29 DISSECTION OF CAROTID ARTERY - DISSECTION OF OTHER ARTERY

443.81 - 443.89 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE - OTHER PERIPHERAL VASCULAR DISEASE

443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED

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

ARTERY

445.01 - 445.02 ATHEROEMBOLISM OF UPPER EXTREMITY - ATHEROEMBOLISM OF LOWER EXTREMITY

445.81 ATHEROEMBOLISM OF KIDNEY

445.89 ATHEROEMBOLISM OF OTHER SITE

446.1 ACUTE FEBRILE MUCOCUTANEOUS LYMPH NODE SYNDROME (MCLS)

446.7 TAKAYASU'S DISEASE

458.0 ORTHOSTATIC HYPOTENSION

458.21 - 458.29 HYPOTENSION OF HEMODIALYSIS - OTHER IATROGENIC HYPOTENSION

458.8 OTHER SPECIFIED HYPOTENSION

458.9 HYPOTENSION UNSPECIFIED

518.4 ACUTE EDEMA OF LUNG UNSPECIFIED

518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

674.82 OTHER COMPLICATIONS OF PUERPERIUM WITH DELIVERY WITH POSTPARTUM COMPLICATION

674.84 OTHER COMPLICATIONS OF PUERPERIUM

710.0 SYSTEMIC LUPUS ERYTHEMATOSUS

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 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL)

747.11 INTERRUPTION OF AORTIC ARCH

747.9 UNSPECIFIED CONGENITAL ANOMALY OF CIRCULATORY SYSTEM

759.3 SITUS INVERSUS

759.82 MARFAN SYNDROME

770.81 PRIMARY APNEA OF NEWBORN

770.82 OTHER APNEA OF NEWBORN

770.88 HYPOXEMIA OF NEWBORN

770.89 OTHER RESPIRATORY PROBLEMS AFTER BIRTH

771.83 BACTEREMIA OF NEWBORN

779.81 NEONATAL BRADYCARDIA

779.82 NEONATAL TACHYCARDIA

779.89 OTHER SPECIFIED CONDITIONS ORIGINATING IN THE PERINATAL PERIOD

780.1 COMA

780.2 TRANSIENT ALTERATION OF AWARENESS

780.2 SYNCOPE AND COLLAPSE

780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED

780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED

780.60 FEVER, UNSPECIFIED

780.61 FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE

780.62 POSTPROCEDURAL FEVER

782.3 EDEMA

782.5 CYANOSIS

784.3 APHASIA

785.1 PALPITATIONS

785.2 UNDIAGNOSED CARDIAC MURMURS

785.3 OTHER ABNORMAL HEART SOUNDS

785.50 SHOCK UNSPECIFIED

785.51 CARDIOGENIC SHOCK

785.52 SEPTIC SHOCK

785.59 OTHER SHOCK WITHOUT TRAUMA

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 UNSPECIFIED CHEST PAIN

786.51 PRECORDIAL PAIN

786.59 OTHER CHEST PAIN

790.7 BACTEREMIA

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

807.4 FLAIL CHEST

861.1 CONTUSION OF HEART WITHOUT OPEN WOUND INTO THORAX

861.2 LACERATION OF HEART WITHOUT PENETRATION OF HEART CHAMBERS OR OPEN WOUND INTO THORAX

861.3 LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS WITHOUT OPEN WOUND INTO THORAX

861.10 UNSPECIFIED INJURY OF HEART WITH OPEN WOUND INTO THORAX

861.13 LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS AND OPEN WOUND INTO THORAX

901.0 INJURY TO THORACIC AORTA

901.2 INJURY TO SUPERIOR VENA CAVA

901.41 INJURY TO PULMONARY ARTERY

901.42 INJURY TO PULMONARY VEIN

958.1 AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA

958.2 FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA

958.4 TRAUMATIC SHOCK

963.1 POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS 990 EFFECTS OF RADIATION UNSPECIFIED

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

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

996.00 - 996.09 MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT - OTHER MECHANICAL COMPLICATION OF CARDIAC DEVICE IMPLANT AND GRAFT

996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT

996.60 INFECTION AND INFLAMMATORY REACTION DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT

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

996.62 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT

996.63 INFECTION AND INFLAMMATORY REACTION DUE TO NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT

996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS

996.71 OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS

996.72 OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT

996.83 COMPLICATIONS OF TRANSPLANTED HEART

997.1 CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED

998.00 - 998.09 POSTOPERATIVE SHOCK, UNSPECIFIED - POSTOPERATIVE SHOCK, OTHER

998.51 INFECTED POSTOPERATIVE SEROMA

998.59 OTHER POSTOPERATIVE INFECTION

999.31 - 999.39 OTHER AND UNSPECIFIED INFECTION DUE TO CENTRAL VENOUS CATHETER - INFECTION FOLLOWING OTHER INFUSION, INJECTION, TRANSFUSION, OR VACCINATION

V42.1* HEART REPLACED BY TRANSPLANT

V42.2* HEART VALVE REPLACED BY TRANSPLANT V43.3* HEART VALVE REPLACED BY OTHER MEANS

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

V72.83 OTHER SPECIFIED PRE-OPERATIVE EXAMINATION

V81.2 SCREENING FOR OTHER AND UNSPECIFIED CARDIOVASCULAR CONDITIONS

* 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

1. Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. The quality of images obtained on any given exam is dependent on the instrumentation, the operator and the patient.

2. At a minimum, a complete study should contain M mode and/or 2D measurements of LV end diastolic diameter, LV end systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion and a qualitative description of the LV function, whenever possible given any technical limitations in a particular case. Individual echocardiographic laboratories (providers) may choose valid substitutes for these parameters such as LV volumes, ejection fraction and mass measurements.

3. A Doppler interrogation should state the modes used and should give both qualitative and quantitative information where appropriate.

4. Claims for contrast echocardiography services must be supported by documentation that conventional studies were inconclusive and there was a need for the contrast enhancement.

5. Documentation 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 Carrier Advisory Committee

ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography, J Am Soc Echocardiogr ;24,229-67.

American College of Cardiology/American Heart Association (2003). Guideline update for clinical application of echocardiography. Circulation 108:1146-1162. Used to support indications and limitations of service.

American College of Cardiology, Guidelines for the Clinical Application of Echocardiography, www.acc.org. Used to support indications and limitations of service.

Braunwald, E., (2001). Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: W.B. Saunders Company, 2001. Used to define the service.

“Echocardiography,” TrailBlazer LCD, (00400) L16396, (00900) L16328, (04302). L26534. Empire Medical Services LMRP

Otto, C.M., (2002). The Practice of Clinical Echocardiography. 2nd ed. Philadelphia, PA: W.B. Saunders Company.

Quinones, M.A., et al. (2003). “ACC/AHA Clinical Competence Statement on Echocardiography.” Journal of the American College of Cardiology. 41.4 687-708.

“Transthoracic Echocardiography (TTE),” Noridian Administrative Services, LLC LCD, (CO) L14929. “Transthoracic Echocardiography (TTE),” Arkansas BlueCross BlueShield (Pinnacle) LCD, (NM, OK) L9767.

“Transthoracic Echocardiography (TTE),” Highmark Medicare Services LCD (12102),L27536. 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.

Florida Contractor Advisory Committee Meeting held on June 18, 2011.

Puerto Rico/U.S. Virgin Islands Contractor Advisory Committee Meeting held on June 23, 2011.

Start Date of Comment Period 06/03/2011

End Date of Comment Period 07/18/2011

Start Date of Notice Period 09/02/2011

Revision History Number 3

Revision History Explanation Revision Number:3 Start Date of Comment Period:06/03/2011

Start Date of Notice Period:09/02/2011 Revised Effective Date: 10/16/2011

LCR B2011-090

September 2011 Connection

Explanation of Revision: Revisions were made under the “Indications and Limitations of Coverage and /or Medical Necessity” section to update the application of coverage and clarify utilization of testing for the conditions and diagnosis listed. Also, the ‘Sources of Information and Basis for Decision” section of the LCD was also updated.

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:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9 CM Update. Deleted diagnosis code 444.0 and 998.0. Added new diagnosis codes 414.4, 444.01, 998.00-998.09, 999.32, 999.33 and 999.34. 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:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Deleted ICD-9-CM code 275.0. Added ICD-9-CM code range 275.01-275.09. 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 Update

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 (L29296) replaces LCD L6659 as the policy in notice. This document (L29296) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 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:

93306 descriptor was changed in Group 1 93307 descriptor was changed in Group 1 93308 descriptor was changed in Group 1 93320 descriptor was changed in Group 1 93321 descriptor was changed in Group 1

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

Reason for Change