L29941-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Renal Angiography (L29941)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29941

LCD Title

Renal Angiography

Contractor's Determination Number 36251

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 06/30/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2012

Revision Ending Date

CMS National Coverage Policy 42 CFR Section 410.32

CMS Change Request 2503, dated 07/03/03

Indications and Limitations of Coverage and/or Medical Necessity

Diagnostic arteriography is an invasive method of evaluating vascular disease. It involves percutaneous passage of a needle and/or catheter into an artery under fluoroscopic guidance, followed by injection of contrast material and imaging of the vascular distribution in question using serial film or digital imaging systems, under conscious sedation.

With modern noninvasive imaging techniques (e.g., duplex ultrasonography, gadolinium enhanced magnetic resonance angiography (MRA), computed tomographic angiography (CTA)), the need for renal arteriography has been significantly reduced. Currently, renal arteriography is mainly used in conjunction with lesions that can potentially be treated or to analyze renal vasculature preoperatively.

INDICATIONS

A. SELECTIVE RENAL ANGIOGRAPHY

FCSO Medicare will consider renal angiography, selective, medically reasonable and necessary for a patient under any of the following circumstances:

• Renovascular occlusive disease (e.g., for hypertension or progressive renal insufficiency)

• Renovascular trauma

• Primary vascular abnormalities, including aneurysms, vascular malformations, and vasculitis

• Renal tumors

• Hematuria of unknown cause

• Pre- and postoperative evaluations for renal transplantation

• Prior to interventional procedures on the renal arteries

B. NON-SELECTIVE RENAL ANGIOGRAPHY PERFORMED AT TIME OF CARDIAC CATHETERIZATION

While withdrawing the catheter during a cardiac catheterization procedure, providers often inject a small amount of dye to examine the renal arteries. This procedure, renal artery angiography, non-selective, when performed at the time of cardiac catheterization, should be reported as HCPCS code G0275 if selective catheterization of the renal artery is not performed.

Renal angiography, non-selective, performed at time of cardiac catheterization [G0275] will be considered medically reasonable and necessary when the clinical index of suspicion for atherosclerotic renal artery stenosis (RAS) is high, as defined by the criteria listed below, AND there are reasonable anticipated therapeutic implications for which the results of this angiogram will be used AND when the results of noninvasive imaging studies cannot be obtained or are inconclusive:

• Onset of severe hypertension before age 30 or severe hypertension after age 55

• Exacerbation of previously well controlled hypertension

• Resistant hypertension (i.e., failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a diuretic)

• Malignant hypertension (hypertension with coexistent evidence of acute end-organ damage; i.e., acute renal failure, acutely decompensated congestive heart failure, new visual or neurological disturbance, and/or advanced [grade III to IV] retinopathy)

• New azotemia or worsening renal function after the administration of an ACE inhibitor or an angiotensin receptor

-blocking agent

• Unexplained atrophic kidney (7 to 8 cm) or a discrepancy in size between the two kidneys of greater than 1.5 cm.

o Note: The atrophy should be otherwise unexplained by a prior history of chronic pyelonephritis, reflux nephropathy, trauma, etc. When such a history is present, there is usually not an indication for additional renal diagnostic tests to define RAS.

• Sudden, unexplained pulmonary edema (especially in azotemic patients)

• Unexplained renal failure, including patients starting renal replacement therapy (dialysis or renal transplantation)

Diagnostic evaluation for renal hypertension is indicated for hypertension that is refractory, of recent onset, or requires a sudden increase in antihypertensive medication to control.

Resistant or refractory hypertension generally refers to patients whose blood pressure (BP) remains uncontrolled (often with systolic blood pressure (SBP) of 160 mm Hg or more and diastolic blood pressure (DBP) of 100 mm Hg or more) despite sustained therapy with three or more antihypertensive drugs including a diuretic.

LIMITATIONS:

• Renal catheter-based contrast arteriography, the longstanding “gold standard” for the diagnosis of renal artery stenosis (RAS), has been largely replaced as a practical first-line modality by noninvasive imaging studies (e.g., duplex ultrasonography, gadolinium enhanced magnetic resonance angiography (MRA), computed tomographic angiography (CTA)). Renal arteriography services will be denied without a prior non-invasive renal artery study that is inconclusive or unavailable. Exceptions to this rule may occur in patients with fibromuscular dysplasia or renal artery aneurysms where there may be branch involvement.

• Routine non-selective renal arteriography, pejoratively called “drive-by angiography”, performed at the time of cardiac catheterization in the absence of accepted clinical indications that support medical necessity, as mentioned in this LCD, will be denied as such services are generally not indicated. In addition, the treating physician must specifically request this extra-cardiac angiographic service.

• A provider should not report CPT codes 36251, 36252, 36253 or 36254 (renal angiography, selective) unless the renal artery(s) is (are) catheterized and a complete renal angiogram, including the venous phase, is performed and interpreted.

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

SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S),

36251 FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; UNILATERAL

SELECTIVE CATHETER PLACEMENT (FIRST-ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE AND CATHETER PLACEMENT(S),

36252 FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; BILATERAL

36253

SUPERSELECTIVE CATHETER PLACEMENT (ONE OR MORE SECOND ORDER OR HIGHER RENAL ARTERY BRANCHES) RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE, CATHETERIZATION, FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; UNILATERAL

SUPERSELECTIVE CATHETER PLACEMENT (ONE OR MORE SECOND ORDER OR HIGHER RENAL ARTERY BRANCHES) RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY,

36254 INCLUDING ARTERIAL PUNCTURE, CATHETERIZATION, FLUOROSCOPY, CONTRAST INJECTION(S), IMAGE POSTPROCESSING, PERMANENT RECORDING OF IMAGES, AND RADIOLOGICAL SUPERVISION AND

INTERPRETATION, INCLUDING PRESSURE GRADIENT MEASUREMENTS WHEN PERFORMED, AND FLUSH AORTOGRAM WHEN PERFORMED; BILATERAL

RENAL ANGIOGRAPHY, NON-SELECTIVE, ONE OR BOTH KIDNEYS, PERFORMED AT THE SAME TIME AS CARDIAC CATHETERIZATION AND/OR CORONARY ANGIOGRAPHY, INCLUDES POSITIONING OR

G0275 PLACEMENT OF ANY CATHETER IN THE ABDOMINAL AORTA AT OR NEAR THE ORIGINS (OSTIA) OF THE RENAL ARTERIES, INJECTION OF DYE, FLUSH AORTOGRAM, PRODUCTION OF PERMANENT IMAGES, AND

RADIOLOGIC SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)

ICD-9 Codes that Support Medical Necessity

ICD-9-CM Codes Applicable for 36251, 36252, 36253 and 36254:

189.1 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS

189.2 MALIGNANT NEOPLASM OF RENAL PELVIS

198.0 SECONDARY MALIGNANT NEOPLASM OF KIDNEY

223.1 BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS

223.2 BENIGN NEOPLASM OF RENAL PELVIS

233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS

401.0 MALIGNANT ESSENTIAL HYPERTENSION

405.01 MALIGNANT RENOVASCULAR HYPERTENSION

405.11 BENIGN RENOVASCULAR HYPERTENSION

405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION

440.1 ATHEROSCLEROSIS OF RENAL ARTERY

441.1 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE

441.2 DISSECTION OF AORTA THORACIC

441.3 DISSECTION OF AORTA ABDOMINAL

441.4 DISSECTION OF AORTA THORACOABDOMINAL

441.1 THORACIC ANEURYSM RUPTURED

441.2 THORACIC ANEURYSM WITHOUT RUPTURE

441.3 ABDOMINAL ANEURYSM RUPTURED

441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE

441.5 AORTIC ANEURYSM OF UNSPECIFIED SITE RUPTURED

441.6 THORACOABDOMINAL ANEURYSM RUPTURED

441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE

441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE

442.1 ANEURYSM OF RENAL ARTERY

442.2 ANEURYSM OF ILIAC ARTERY

442.83 ANEURYSM OF SPLENIC ARTERY

442.84 ANEURYSM OF OTHER VISCERAL ARTERY

443.22 DISSECTION OF ILIAC ARTERY

443.23 DISSECTION OF RENAL ARTERY

444.01 - 444.09SADDLE EMBOLUS OF ABDOMINAL AORTA - OTHER ARTERIAL EMBOLISM AND

THROMBOSIS OF ABDOMINAL AORTA

444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY

445.02 ATHEROEMBOLISM OF LOWER EXTREMITY

445.81 ATHEROEMBOLISM OF KIDNEY

447.3 HYPERPLASIA OF RENAL ARTERY

447.6 ARTERITIS UNSPECIFIED

557.1 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE

557.2 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE

557.9 UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE

593.81 VASCULAR DISORDERS OF KIDNEY

593.9 UNSPECIFIED DISORDER OF KIDNEY AND URETER

599.70 HEMATURIA, UNSPECIFIED

747.62 RENAL VESSEL ANOMALY

794.4 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY

902.40 INJURY TO RENAL VESSEL(S) UNSPECIFIED

959.12 OTHER INJURY OF ABDOMEN

959.8 OTHER AND UNSPECIFIED INJURY TO OTHER SPECIFIED SITES INCLUDING MULTIPLE

996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT

V42.0* KIDNEY REPLACED BY TRANSPLANT

V58.44 AFTERCARE FOLLOWING ORGAN TRANSPLANT

* According to the ICD-9-CM book, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as a primary diagnosis.

ICD-9-CM Codes Applicable for G0275:

401.0 MALIGNANT ESSENTIAL HYPERTENSION

402.1 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE

402.2 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

403.1 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED

403.2 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART

404.00 -

404.03 opens in new window

404.10 -

404.13 opens in new window

FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

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

405.01 MALIGNANT RENOVASCULAR HYPERTENSION

405.11 BENIGN RENOVASCULAR HYPERTENSION

440.1 ATHEROSCLEROSIS OF RENAL ARTERY

442.1 ANEURYSM OF RENAL ARTERY

445.81 ATHEROEMBOLISM OF KIDNEY

447.3 HYPERPLASIA OF RENAL ARTERY

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 clearly indicate medical necessity and made available to Medicare upon request.

This documentation should include, but is not limited to the following:

• Relevant medical history

• Physical examination

• Previous noninvasive diagnostic evaluation(s) to substantiate medical necessity

• Detailed summary of the procedure report (including interpretation of venous phase when selective angiography is performed) and a description of the angiographic findings

Documentation must support the criteria for coverage as set forth in the ‘Indications and Limitations of Coverage and/or Medical Necessity’ section of this LCD and should reflect how the results of this test will be used in the patient’s plan of care.

Documentation must indicate that the treating physician has specifically ordered any extra-cardiac angiographic service performed.

If the provider of the test is other than the ordering/referring physician, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician’s order for the test.

Per 42 CFR §410.32, all diagnostic tests must be ordered by the physician who is treating the patient, that is, the physician who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem. Tests not ordered by the physician who is treating

the patient are not reasonable and necessary.

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

American College of Radiology Practice Guidelines. (2007). ACR practice guidelines for the performance of diagnostic arteriorgraphy in adults. Retrieved 07/30/08 from http://www.acr.org.

American College of Radiology Practice Guidelines. (2004). ACR Practice guidelines for the performance of angiography, angioplasty, and stenting for the diagnosis and treatment of renal artery stenosis in adults. (Amended 2007). Retrieved 07/30/08 from http://www.acr.org

American College of Cardiology Foundation and American Heart Association. (2005). ACR Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American association for vascular surgery/society for vascular surgery, society for cardiovascular angiography and interventions, society for vascular medicine and biology, society of interventional radiology, and the ACC/AHA task force on practice guidelines. Retrieved August 1 2008 from http://circ.ahajournals.org

American Medical Association. (2004). Interventional radiology coding users’ guide. (10th ed.).

White, C., Jaff, M., Haskal, Z., Jones, D., Olin, J., Rocha-Singh, K., Rosenfield, K., Rundback, J., & Linas, S. (2006). Indications for renal arteriography at the time of coronary arteriography. A science advisory from the American heart association committee on diagnostic and interventional cardiac catheterization, council on clinical cardiology, and the councils on cardiovascular radiology and intervention and on kidney in cardiovascular disease.

Circulation. Retrieved 08/01/08 from http://cir.ahajournals.org 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/U.S. Virgin Islands Contractor Advisory Meeting held on March 19, 2009.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 05/01/2009

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2012 Revised Effective Date: 01/01/2012

LCR B2012-010

December 2011 Connection

Explanation of Revision: Annual 2012 HCPCS Update. CPT codes 75722 and 75724 were deleted and replaced with CPT codes 36251 – 36254. Contractor’s Determination Number 75722 was changed to 36251. 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:10/01/2011 Revised Effective Date: 10/01/2011

LCR B2011-101

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. For CPT codes 75722 and 75724, deleted diagnosis code

444.0 and replaced it with new diagnosis code range 444.01-444.09. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:02/20/2009 Start Date of Notice Period:05/01/2009 Original Effective Date: 06/30/2009

LCR B2009-061

April 2009 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:

75722 descriptor was changed in Group 1 75724 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update. 11/21/2011 - The following CPT/HCPCS codes were deleted:

75722 was deleted from Group 1

75724 was deleted from Group 1

Reason for Change