L29412-LCD

Automated World Health

Local Coverage Determination (LCD) for Cardiovascular Stress Testing (L29412)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29412

LCD Title Cardiovascular Stress Testing

Contractor's Determination Number 93015

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 06/30/2009 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (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 represent quotation from one or more of the following CMS sources: N/A

Indications and Limitations of Coverage and/or Medical Necessity

Cardiovascular Stress Testing or Exercise Stress Test (EST) consists of the continuous monitoring of an electrocardiogram (generally a 12-lead system) with frequent 3-lead or 12-lead recordings taken according to clinical circumstances, frequent blood pressure determinations and continuous patient observation before, during and after exercise of progressively increasing intensity (usually with a treadmill or cycle ergometer) to any of a number of test end points. Usually, the heart rate, blood pressure, and EKG are recorded at the end of each stage of exercise, immediately before and immediately after stopping exercise, and for each minute for at least 5-10 minutes in the recovery stage. A minimum of three leads should be displayed continuously on the cathode ray screen during the test. Arm exercise is occasionally used in selected patients, although it is seldom as

satisfactory.

Exercise Stress Testing is valuable for diagnosing ischemic heart disease and in investigating physiologic mechanisms underlying cardiac symptoms, such as angina, dysrhythmias, inordinate rises in blood pressure, and functional valve incompetence. EST also measures functional capacity for work, sport, or participation in a rehabilitation program and estimates response to medical or surgical treatment. Additionally, the function of physiologic responsive pacemakers (testing for upper rate limits) can be evaluated.

Normally, the systolic blood pressure increases with exercise and the diastolic remains essentially unchanged. An exercise test is considered negative when the patient does not exhibit significant symptoms, arrhythmias, or other ECG abnormalities at 85% of maximum heart rate predicted for age and sex.

In many instances, exercise testing may be combined with other procedures, such as myocardial perfusion imaging, radionuclide ventriculography, echocardiography or other imaging procedures.

FCSO Medicare will consider a cardiovascular stress test medically reasonable and necessary for the following conditions:

• To evaluate the prognosis and functional capacity of patients with Coronary Artery Disease (CAD) soon after a myocardial infarction (before discharge or early after discharge and again 6-8 weeks after uncomplicated MI).

• To assess for the presence or absence of coronary disease, appropriate heart rate and/or blood pressure response for cardiac transplant patients. For optimal management of these patients, annual testing is recommended.

• Evaluation of patients before and after coronary artery revascularization by the following methods:

o Coronary Artery Bypass Grafting (CABGs). Testing is recommended in patients with suspected incomplete revascularization, technical difficulties during or after the operation, initial difficulties in being disconnected from the extra corporeal support system, enzymatic or electrocardiographic evidence of intraoperative MI, or other evidence of perioperative complications.

o Percutaneous Coronary Intervention (PCI)). Testing is performed prior to discharge (1-3 days after procedure) and again at 3 to 6 months (helps identify the 20-30% of patients who restenose in the first 6 months after the procedure).

• To evaluate functional capacity serially in the course of an exercise cardiac rehabilitation program (prior to starting rehab and at 12 weeks).

• Initial evaluation of patients with symptoms consistent with recurrent, exercise-induced cardiac arrthymias (e.g., shortness of breath (SOB) on exertion, syncope, palpitations, etc.).

• Initial evaluation of exercise capacity of selected patients with valvular heart disease with related symptomatology.

• Initial diagnostic workup for a patient that presents with abnormal signs and symptoms such as chest pain, palpitations, dyspnea, etc., which may suggest a cardiac origin. (Including those with RBBB or less than 1 mm ST depression, with an intermediate pre-test probability of CAD).

• Initial evaluation of patients with new onset of arrhythmias.

• Initial evaluation of a patient with an old Myocardial Infarction in which a workup has not been previously performed.

• Evaluation of a patient presenting with recent changes in an ECG.

• Evaluation of a patient with known CAD that presents with new symptoms such as increasing SOB, palpitations, change in EKG, etc.

• Evaluate patient’s response to a newly established therapy for angina, palpitations, arrhythmias, SOB or any other cardiopulmonary disease process.

• Evaluation of other symptomatology which may indicate a cardiac origin especially in those patients who have a history of a MI, CABG surgery or PCI or patients who are being treated medically after a positive stress test or cardiac catheterization.

General contraindications to exercise testing include:

• Very recent acute myocardial infarction (generally within 2 days)

• High risk, unstable angina

• Uncontrolled asymptomatic heart failure

• Untreated cardiac arrhythmia causing symptoms or hemodynamic compromise

• Acute pericarditis, myocarditis or endocarditis

• Symptomatic severe aortic stenosis (calculated effective orifice less than .75 cm2 /m2 BSA or a peak systolic pressure gradient exceeding 50 mg Hg in presence of normal cardiac output)

• Severe arterial hypertension (generally > 200 mmHg systolic or 110 mmHg diastolic)

• Acute pulmonary embolus or pulmonary infarction

• Acute aortic dissection

• Acute or serious noncardiac disorder

Patients with an abnormal resting ECG because of left bundle branch block, pre-excitation syndrome, left ventricular hypertrophy (LVH) or digoxin therapy, an exercise or pharmacological imaging study should be considered, because the accuracy of the exercise ECG in detecting provokeable ischemia is reduced.

Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests including echocardiography and nuclear cardiac imaging. Medicare expects that only the most appropriate test(s) necessary will be performed and billed to Medicare. The routine and repetitive monitoring of such patients beyond the first cardiac stress test, in the absence of a documented change in condition (i.e. new symptoms or progression of existing symptoms) is not considered medically necessary.

Specific coverage of additional cardiac diagnostic tests e.g., (nuclear cardiac imaging studies) is outside the scope of the LCD. Please refer to LCDs related to those procedures for details of their coverage.

Exercise testing should be supervised by an appropriately trained physician. Exercise testing in selected patients can be performed safely by properly trained nurses, exercise physiologists, physician assistants, physical therapists, or medical technicians working directly under the supervision of a physician, who should be in the immediate vicinity and available for emergencies.

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.

999x Not Applicable

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

93015 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; WITH PHYSICIAN SUPERVISION, WITH INTERPRETATION AND REPORT

93016 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, 93016 CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; PHYSICIAN SUPERVISION ONLY, WITHOUT INTERPRETATION AND REPORT

93017 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT

93018 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; INTERPRETATION AND REPORT ONLY

ICD-9 Codes that Support Medical Necessity

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

392.0 RHEUMATIC CHOREA WITH HEART INVOLVEMENT

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

398.0 - 398.99 RHEUMATIC MYOCARDITIS - OTHER RHEUMATIC HEART DISEASES

402.00 - 402.91 MALIGNANT 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 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE

410.00 - 410.92 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 - 414.9 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - 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

424.1 MITRAL VALVE DISORDERS

424.2 AORTIC VALVE DISORDERS

426.0 - 426.9 ATRIOVENTRICULAR BLOCK COMPLETE - CONDUCTION DISORDER UNSPECIFIED

427.0 - 427.9 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - CARDIAC DYSRHYTHMIA UNSPECIFIED CONGESTIVE HEART FAILURE

428.0 - 428.9 UNSPECIFIED - HEART FAILURE UNSPECIFIED

780.2 SYNCOPE AND COLLAPSE

780.4 DIZZINESS AND GIDDINESS

785.1 TACHYCARDIA UNSPECIFIED

785.2 PALPITATIONS

785.3 UNDIAGNOSED CARDIAC MURMURS

785.4 OTHER ABNORMAL HEART SOUNDS

786.00 - 786.09 RESPIRATORY ABNORMALITY UNSPECIFIED - RESPIRATORY ABNORMALITY OTHER

786.50 - 786.59 UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) V42.1* HEART REPLACED BY TRANSPLANT

V45.01* CARDIAC PACEMAKER IN SITU

V45.81* POSTSURGICAL AORTOCORONARY BYPASS STATUS

V45.82* PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY V67.09 FOLLOW-UP EXAMINATION FOLLOWING OTHER SURGERY

V67.59 OTHER FOLLOW-UP EXAMINATION

* According to the ICD-9-CM book, Diagnosis codes V42.1, V45.01, V45.81, and V45.82 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 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

Medical record documentation maintained by the ordering/referring physician must indicate the medical necessity for performing the test, including:

• history and physical

• office/progress note, and

• test results

If the provider of the service 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. The physician must state the clinical indication/medical necessity for the study in his order for the test.

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.

Reimbursement of cardiovascular stress testing (93015-93018) which exceeds the frequency or duration indicated by the accepted standards of medical practice are not covered unless there are special circumstances which justify additional cardiovascular stress testing. The routine and repetitive monitoring of such patients beyond the first cardiac stress test, in the absence of a documented change in condition (i.e. new symptoms or progression of existing symptoms) is not considered medically necessary.

Sources of Information and Basis for Decision

American College of Cardiology (ACC) /American Heart Association (AHA) (2002). Guideline update for exercises testing. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee on Exercise Testing.

Braunwald, E., (2007). Heart Disease: A Textbook of Cardiovascular Medicine (8th ed.). Philadelphia: W.B. Saunders Company.

Rodgers, et.al, (2000). Clinical Competence Statement on Stress Testing. College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing. Journal of American College Cardiology. (36) 1441-

53. 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 March 7, 2009.

Puerto Rico/Virgin Islands Contractor Advisory Meeting held on March 19, 2009.

Start Date of Comment Period 02/20/2009

End Date of Comment Period 04/06/2009

Start Date of Notice Period 05/01/2009

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:02/20/2009

Start Date of Notice Period:05/01/2009 Original Effective Date: 06/30/2009

LCR B2009-066

April 2009 Update

Explanation of Revision: A major revision was done to update the indications and limitation of coverage and/or medical necessity based on the 2002 ACC/AHA Guidelines for Cardiovascular Stress Testing. The previous LCD was stricken in its entirety. Language was added to the “Indications and Limitations of Coverage and/or Medical Necessity: section. The “ICD-9 Codes that Support Medical Necessity” section was revised. The following ICD-9- CM codes were added: 391.0-391.9, 392.0, 398.0-398.99, 402.90-402.91, 414.06, 414.07, 414.12, 414.2,

414.3, 415.0-415.19, 416.0-416.9, 426.10, 426.11, 426.7, 426.81-426.89, 426.9, 427.1, 427.60, 427.61,

427.81, 427.89, 427.9, 780.4, 785.0, 785.1, 785.2, 785.3, 786.00-786.01, 786.03-786.04, 786.06-786.07,

786.52, 786.59, V67.00, V67.09, V67.59. The following ICD-9- CM codes were deleted: 424.2, 424.3, 425.0 –

425.9, 429.0-429.6, 429.71-429.79, 429.81-429.89, 429.9, 746.85, 972.9, 996.72, 996.83, E933.1, V15.1,

V42.2, V42.6, V43.3, V67.2, V67.51, and V71.7. Language was also added to the “Documentation Requirements”, “Utilization Guidelines”, and “Sources of Information and Basis for Decision” sections of the LCD. The effective date of this revision is based on dates 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-

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) there was no previous LCD on this subject. This document (L29412) is effective on 02/02/2009.

Reason for Change