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Contractor's Policy Number

99-05-R4

Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Title

Cardiac Catheterization

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply.

CMS National Coverage Policy

  • Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
  • Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
  • Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

08/27/1999

Original Policy Ending Date

 

Revision Effective Date

10/01/2003

Revision Ending Date

09/30/2003

LMRP Description

  • Cardiac catheterization is a technique in which a flexible catheter is passed along veins or arteries into the heart and associated vessels for the measurement of physiological data and imaging of the heart and great vessels.
  • This technique is utilized when there is a need to confirm the presence of a clinically suspected condition, define its anatomical and physiological severity, and determine the presence of associated conditions.
  • This need most commonly arises when clinical assessment suggests that the patient may benefit from an interventional procedure (i.e., coronary angioplasty, balloon valvuloplasty) or heart surgery.

Indications and Limitations of Coverage and/or Medical Necessity

Left Heart Catheterization

A left heart catheterization may be considered medically necessary for patients with any of the following conditions:

  • There is evidence of high risk on noninvasive testing:
    • The exercise ECG testing documents an abnormal ST segment depression (magnitude equal to or greater than 1.5 mm depression, persistent post-exercise changes, depression in multiple leads),
    • There is an abnormal systolic blood pressure response during progressive exercise, with sustained decrease of greater than 10 mmHg or flat blood pressure (less than or equal to 130 mmHg) associated with ECG evidence of ischemia,
    • There are other potentially important determinants such as exercise induced ST segment elevation in leads other than aVR or exercise induced ventricular tachycardia,
    • Thallium scintigraphy documents an abnormal thallium distribution in the anterior wall or more than one vascular region at rest or with exercise, or an abnormal distribution (ischemia) associated with increased lung uptake produced by exercise in the absence of severely depressed left ventricular function at rest,
    • Radionuclide ventriculography documents a fall in ventricular ejection fraction of greater than or equal to 10 percent during exercise, or left ventricular ejection fraction of less than 50 percent at exercise or rest when suspected to be due to coronary artery disease; or,
    • The stress echocardiography shows contraction abnormalities in the anterior wall or more than one vascular region at rest or with exercise.
  • There is successful resuscitation from cardiac arrest that occurred without obvious precipitating cause, when a reasonable suspicion of coronary artery disease exists,
  • There is the presence of two or more major risk factors and a positive exercise test in patients without known coronary heart disease,
  • There is the presence of prior myocardial infarction with normal left ventricular function at rest, and evidence of ischemia by noninvasive testing,
  • There is evidence of ischemia by noninvasive testing after coronary bypass surgery or percutaneous transluminal angioplasty,
  • Evaluation before high-risk non-cardiac surgery in patients who have evidence of ischemia by noninvasive testing,
  • Evaluation of patients after cardiac transplantation,
  • Angina pectoris that has proven inadequately responsive to medical treatment, percutaneous transluminal angioplasty, thrombolytic therapy, or coronary bypass surgery,

Note: "Inadequately responsive" is taken to mean that patient and physician agree that angina significantly interferes with a patient's occupation or ability to perform his/her usual activities.

  • Unstable angina pectoris which is defined as:
    • Increased severity and frequency of chronic angina pectoris within the past two months, despite medical management, including onset of angina at rest,
    • New onset (within two months) of angina pectoris which is severe or increases despite medical treatment; or,
    • Acute coronary insufficiency, with pain at rest usually of greater than or equal to 15 minutes duration, associated with ST-T wave changes, within the preceding two weeks.
  • Prinzmetal's or variant angina pectoris (pain experienced at rest),
  • Any angina pectoris in association with any of the following:
    • Evidence of high risk as manifested by exercise ECG testing in addition to failure to complete Stage II of Bruce protocol or equivalent workload (less than or equal to 6.5 METS with other protocols) due to ischemic cardiac symptoms,
    • exercise heart rate at onset of limiting ischemia symptoms of less that 120/minutes (without beta blockers),
    • Evidence of high risk as manifested by radionuclide exercise testing (thallium scintigraphy or radionuclide ventriculography); or,
    • Stress echocardiography showing contraction abnormalities in the anterior wall or more than one vascular region at rest or with exercise.
  • The coexistence of a history of myocardial infarction, a history of hypertension and ST segment depression on the baseline ECG,
  • In disease affecting the aorta when knowledge of the presence or extent of coronary artery involvement is necessary for management (for example, the presence of aortic aneurysm or ascending aortic dissection), arteritis or homozygous type II hypercholesterolemia in which coronary artery involvement suspected,
  • The presence of left ventricular failure without obvious cause and adequate left ventricular systolic function,
  • When patients with hypertrophic cardiomyopathy have angina pectoris uncontrolled by medical therapy, or are to undergo surgery for outflow obstruction,
  • The presence of dilated cardiomyopathy,
  • Recent blunt trauma to the chest and evidence of acute myocardial infarction in patients who have no evidence of preexisting coronary heart disease,
  • When patients are to undergo other cardiac surgical procedures, such as pericardiectomy or removal of chronic pulmonary emboli,
  • Episodic pulmonary edema or symptoms of ventricular failure without obvious cause.
    • Any angina pectoris associated with a series of progressively more abnormal exercise ECG or other noninvasive stress tests; or,
    • Any angina pectoris in a patient that cannot be risk stratified by other means as a result of an inability to exercise because of an amputation, arthritis, limb deformity, or severe peripheral vascular disease.

A left heart catheterization may be considered medically necessary for atypical chest pain of uncertain etiology with any of the following situations/conditions:

Note: Atypical chest pain is defined as single or recurrent episodes of chest pain suggestive, but not typical, of the pain of myocardial ischemia. This discomfort may have some features of ischemic pain together with features of non-cardiac pain. Chest pain that has no features of cardiac pain, as well as typical chest pain of myocardial ischemia or angina as determined by a careful medical history, is excluded from definition.

  • Atypical chest pain when ECG or radionuclide stress test indicates that high risk coronary disease may be present;
  • When there are associated symptoms or signs or abnormal left ventricular function or failure;
  • Atypical chest pain when non-invasive studies are questionable or cannot be adequately performed; or,
  • When non-invasive tests are negative but symptoms are severe and management requires that significant coronary artery disease be excluded.

A left heart catheterization may be considered medically necessary after a myocardial infarction (greater than 10 days and up to eight weeks) with any of the following situations/conditions:

  • Angina pectoris occurring at rest or with minimal activity,
  • In selected patients, heart failure during the evolving phase, or left ventricular ejection fraction 45 percent, primarily when associated with some manifestation of recurrent myocardial ischemia or with significant ventricular arrhythmias,
  • Evidence of myocardial ischemia on laboratory testing, exercise or pharmacologic induced ischemia (with or without exercise induced angina pectoris), manifested by greater than or equal to 1 mm of ischemic ST segment depression or exercise induced reversible thallium perfusion defect or defects, or exercise induced reduction in the ejection fraction or wall motion abnormalities on radionuclide ventriculographic studies; or,
  • Mild angina pectoris.

A left heart catheterization may be considered medically necessary for valvular heart disease with any of the following situations/conditions:

  • When valve surgery is being considered in a patient with chest discomfort or ECG changes, or both, suggesting coronary artery disease,
  • When valve surgery is being considered in female patients who are postmenopausal,
  • When aortic or mitral valve surgery is being considered,
  • When one or more major risk factors for coronary artery disease are present; such as heavy smoking history, diabetes mellitus, hypertension, hyperlipidemia, strong family history of premature coronary artery disease; or,
  • In the presence of infective endocarditis when there is evidence of coronary embolism.

Right Heart Catheterization

Right heart catheterization is not routinely part of a left heart catheterization coronary angiography, but is an associated procedure in a significant number of patients. A right heart catheterization may be considered medically necessary for patients with any of the following situations/conditions:

  • Patients with known history of congestive heart failure;
  • Patients with cardiomyopathy documented by non-invasive work-up;
  • Patients with known or suspected valvular heart disease;
  • Patients with known or suspected intracardiac shunt (i.e., shortness of breath), suspected to have cardiac origin; or,
  • Patients in whom pulmonary artery disease is known or suspected (i.e., pulmonary hypertension, status post pulmonary emboli).

Note: It is expected that the medical necessity of the right heart catheterization and the physician's evaluation of a particular patient should be documented on the patient record prior to the procedure being performed.

Combined Heart Catheterization Indications

Combined heart catheterization (right and left) can be useful in providing cardiac output and hemodynamics that may be important therapeutic directives. Medicare expects the specific indications for the individual right and left heart catheterizations to be met prior to performing the combined heart catheterization.

CPT/HCPCS Section & Benefit Category

Medicine

Type of Bill Code

11X, 13X, 14X, 18X, 21X, 28X, 71X, 83X, 85X

Revenue Codes

480, 481

CPT/HCPCS Codes

The AMA and CMS require the use of short descriptors for policies published on the Web. Refer to the CPT book for the long description of the following codes:

93501

©

Right heart catheterization

93510

©

Left heart catheterization

93511

©

Left heart catheterization

93514

©

Left heart catheterization

93524

©

Left heart catheterization

93526

©

Rt & Lt heart catheters

93527

©

Rt & Lt heart catheters

93528

©

Rt & Lt heart catheters

93529

©

Rt, Lt heart catheters

93530

©

Rt heart cath, congenital

93531

©

Rt & LT heart cath, congenital

93532

©

Rt & LT heart cath, congenital

93533

©

Rt & LT heart cath, congenital

93539

©

Injection, cardiac cath

93540

©

Injection, cardiac cath

93541

©

Injection for lung angiogram

93542

©

Injection for heart x-rays

93543

©

Injection for heart x-rays

93544

©

Injection for aortography

93545

©

Inject for coronary x-rays

93555

©

Imaging, cardiac cath

93556

©

Imaging, cardiac cath

© CPT American Medical Association

Not Otherwise Classified (NOC)

N/A

ICD-9 Codes that Support Medical Necessity

ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the claim is submitted.

It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical suspicion must be present for the procedure to be paid.

Medicare is establishing the following limited coverage for codes 93501, 93526, 93527, 93528, 93529, 93530, 93531, 93532, 93533, 93541, and 93542

Covered for:

394.0-394.2

 

Diseases of mitral valve

395.0-395.2

 

Diseases of aortic valve

396.0-396.3

 

Diseases of mitral and aortic valves

396.8

 

Multiple involvement of mitral and aortic valves

398.0

 

Rheumatic myocarditis

398.90-398.91

 

Other and unspecified rheumatic heart diseases

398.99

 

 

402.01

 

Hypertensive heart disease, malignant, with heart failure

402.11

 

Benign, with congestive heart failure

402.91

 

Unspecified, with congestive heart failure

404.01

 

Hypertensive heart and renal disease, malignant, with congestive heart failure

404.03

 

Malignant, with congestive heart failure and renal failure

404.11

 

Benign, with congestive heart failure

404.13

 

Benign, with congestive heart failure and renal failure

404.91

 

Unspecified, with congestive heart failure

404.93

 

Unspecified, with congestive heart failure and renal failure

415.11

 

Iatrogenic pulmonary embolism and infarction

415.19

 

 

416.0

 

Primary pulmonary hypertension

416.8

 

Other chronic pulmonary heart diseases

423.2

 

Constrictive pericarditis

423.9

 

Unspecified disease of pericardium. Note: Use this diagnosis code to report cardiac tamponade.

424.0-424.3

 

Valve disorders

425.0-425.5

 

Cardiomyopathy

425.7-425.9

 

 

428.0

 

Congestive heart failure, unspecified

428.1

 

Left heart failure

428.20

 

Systolic heart failure, unspecified

428.21

 

Systolic heart failure, acute

428.22

 

Systolic heart failure, chronic

428.23

 

Systolic heart failure, acute or chronic

428.30

 

Diastolic heart failure, unspecified

428.31

 

Diastolic heart failure, acute

428.32

 

Diastolic heart failure, chronic

428.33

 

Diastolic heart failure, acute or chronic

428.40

 

Combined systolic and diastolic heart failure, unspecified

428.41

 

Combined systolic and diastolic heart failure, acute

428.42

 

Combined systolic and diastolic heart failure, chronic

428.43

 

Combined systolic and diastolic heart failure, acute or chronic

428.9

 

Heart failure, unspecified

429.71

 

Acquired cardiac septal defect

674.50

 

Peripartum cardiomyopathy, unspecified as to episode of care or not applicable

674.51

 

Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition

674.52

 

Peripartum cardiomyopathy, delivered, with mention of postpartum condition

674.53

 

Peripartum cardiomyopathy, antepartum condition or complication

674.54

 

Peripartum cardiomyopathy, postpartum condition or complication

745.4

 

Ventricular septal defect

745.5

 

Ostium secundum type atrial septal defect

746.6

 

Congenital mitral insufficiency

V12.50

 

Unspecified circulatory disease

Medicare is establishing the following limited coverage for codes 93510-93511, 93514, 93524, 93539, 93540, 93544, and 93545.

Covered for:

394.0-394.2

 

 

395.0-395.2

 

Diseases of aortic valve

.396.0-396.3

 

 

396.8

 

 

401.1

 

Benign essential hypertension

402.10-402.11

 

Benign hypertensive heart disease

402.90-402.91

 

Unspecified hypertensive heart disease

410.00-410.02

 

Acute myocardial infarction of anterolateral wall

410.10-410.12

 

Acute myocardial infarction of other anterior wall

410.20-410.22

 

Acute myocardial infarction of inferolateral wall

410.30-410.32

 

Acute myocardial infarction of inferoposterior wall

410.40-410.42

 

Acute myocardial infarction of other inferior wall

410.50-410.52

 

Acute myocardial infarction of other lateral wall

410.60-410.62

 

Acute myocardial infarction, true posterior wall

410.70-410.72

 

Acute myocardial infarction, subendocardial

410.80-410.82

 

Acute myocardial infarction of other specified sites

410.90-410.92

 

Acute myocardial infarction of unspecified site

411.0

 

Post myocardial infarction syndrome

411.1

 

Intermediate coronary syndrome

411.81

 

Acute coronary occlusion without myocardial infarction

411.89

 

 

412

 

Old myocardial infarction

413.0-413.1

 

Angina pectoris

413.9

 

Other and unspecified angina pectoris

414.00-414.05

 

Coronary atherosclerosis

414.06

 

Of native coronary artery of transplanted heart

414.07

 

Of bypass graft (artery) (vein) of transplanted heart

414.8-414.9

 

 

424.0-424.1

 

Mitral valve and aortic valve disorders

674.50

 

Peripartum cardiomyopathy, unspecified as to episode of care or not applicable

674.51

 

Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition

674.52

 

Peripartum cardiomyopathy, delivered, with mention of postpartum condition

674.53

 

Peripartum cardiomyopathy, antepartum condition or complication

674.54

 

Peripartum cardiomyopathy, postpartum condition or complication

745.5

 

Ostium secundum type atrial septal defect

V12.50

 

Personal history of unspecified circulatory disease

V12.51

 

Personal history of venous thrombosis and embolism

V42.1

 

Organ or tissue replaced by transplant, heart

V42.2

 

Organ or tissue replaced by transplant, heart valve

V43.21

 

Heart assist device

V43.22

 

Fully implantable artificial heart

V43.3

 

Organ or tissue replaced by other means, heart valve

V45.81

 

Other postsurgical status, aortocoronary bypass

V45.82

 

Other postsurgical status, percutaneous transluminal coronary

 

 

angioplasty

Medicare is establishing expanded coverage for procedure code 93543.

Covered for:

394.0-394.2

 

Diseases of mitral valve

395.0-395.2

 

Diseases of aortic valve

396.0-396.3

 

Diseases of mitral and aortic valves

396.8

 

 

398.0

 

Rheumatic myocarditis

398.90-398.91

 

Other and unspecified rheumatic heart diseases

398.99

 

 

401.1

 

Benign essential hypertension

402.10

 

Without heart failure

402.11

 

With heart failure

402.90

 

Unspecified hypertensive heart disease without heart failure

402.91

 

Unspecified hypertensive heart disease with heart failure

410.00-410.02

 

Acute myocardial infarction of anterolateral wall

410.10-410.12

 

Acute myocardial infarction of anterior wall

410.20-410.22

 

Acute myocardial infarction of inferolateral wall

410.30-410.32

 

Acute myocardial infarction of inferoposterior wall

410.40-410.42

 

Acute myocardial infarction of inferior wall

410.50-410.52

 

Acute myocardial infarction of lateral wall

410.60-410.62

 

Acute myocardial infarction of true posterior wall

410.70-410.72

 

Acute myocardial infarction, subendocardial

410.80-410.82

 

Acute myocardial infarction, other unspecified sites

410.90-410.92

 

Acute myocardial infarction, unspecified site

411.0

 

Post myocardial infarction syndrome

411.1

 

Intermediate coronary syndrome

411.81

 

Acute coronary occlusion without myocardial infarction

411.89

 

 

412

 

Old myocardial infarction

413.0-413.1

 

Angina pectoris

413.9

 

Other and unspecified angina pectoris

414.00-414.05

 

Coronary atherosclerosis

414.06

 

Of native coronary artery of transplanted heart

414.07

 

Of bypass graft (artery) (vein) of transplanted heart

414.8-414.9

 

 

415.11

 

Iatrogenic pulmonary embolism and infarction

415.19

 

 

416.0

 

Primary pulmonary hypertension

416.8

 

Other chronic pulmonary heart diseases

423.2

 

Constrictive pericarditis

423.9

 

Unspecified diseases of pericardium

424.0-424.3

 

Valve disorders

425.0-425.5

 

Cardiomyopathy

425.7-425.9

 

 

428.0

 

Congestive heart failure, unspecified

428.1

 

Left heart failure

428.20

 

Systolic heart failure, unspecified

428.21

 

Systolic heart failure, acute

428.22

 

Systolic heart failure, chronic

428.23

 

Systolic heart failure, acute or chronic

428.30

 

Diastolic heart failure, unspecified

428.31

 

Diastolic heart failure, acute

428.32

 

Diastolic heart failure, chronic

428.33

 

Diastolic heart failure, acute or chronic

428.40

 

Combined systolic and diastolic heart failure, unspecified

428.41

 

Combined systolic and diastolic heart failure, acute

428.42

 

Combined systolic and diastolic heart failure, chronic

428.43

 

Combined systolic and diastolic heart failure, acute or chronic

428.9

 

 

429.71

 

Acquired cardiac septal defect

674.50

 

Peripartum cardiomyopathy, unspecified as to episode of care or not applicable

674.51

 

Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition

674.52

 

Peripartum cardiomyopathy, delivered, with mention of postpartum condition

674.53

 

Peripartum cardiomyopathy, antepartum condition or complication

674.54

 

Peripartum cardiomyopathy, postpartum condition or complication

745.4-745.5

 

Ventricular septal defect

746.6

 

Congenital mitral insufficiency

V12.50

 

Unspecified circulatory disease

V12.51

 

Personal history of venous thrombosis and embolism

V42.1

 

Organ or tissue replaced by transplant, heart

V42.2

 

Organ or tissue replaced by transplant, heart valve

V43.21

 

Heart assist device

V43.22

 

Fully implantable artificial heart

V43.3

 

Organ or tissue replaced by transplant, other means, heart valve

V45.81

 

Other post surgical status, aortocoronary bypass

V45.82

 

Other post surgical status, percutaneous transluminal coronary

 

 

angioplasty

Medicare is establishing the following limited coverage for codes 93555 and 93556.

Covered for:

394.0-394.2

 

Diseases of mitral valve

395.0-395.2

 

Diseases of aortic valve

396.0

 

Mitral valve stenosis and aortic valve stenosis

396.1

 

Mitral valve stenosis and aortic valve insufficiency

396.2

 

Mitral valve insufficiency and aortic valve stenosis

396.3

 

Mitral valve insufficiency and aortic valve insufficiency

396.8

 

 

398.0

 

Rheumatic myocarditis

398.90-398.91

 

Other and unspecified rheumatic heart diseases

398.99

 

 

401.1

 

Essential hypertension, benign

402.10

 

Without heart failure

402.11

 

With heart failure

402.90

 

Unspecified hypertensive heart disease, without heart failure

402.91

 

Unspecified hypertensive heart disease, with heart failure

410.00-410.02

 

Acute myocardial infarction of anterolateral wall

410.10-410.12

 

Acute myocardial infarction of other anterior wall

410.20-410.22

 

Acute myocardial infarction of inferolateral wall

410.30-410.32

 

Acute myocardial infarction of inferoposterior wall

410.40-410.42

 

Acute myocardial infarction of other inferior wall

410.50-410.52

 

Acute myocardial infarction of lateral wall

410.60-410.62

 

Acute myocardial infarction, true posterior wall

410.70-410.72

 

Acute myocardial infarction, subendocardial

410.80-410.82

 

Acute myocardial infarction of other specified sites

410.90-410.92

 

Acute myocardial infarction of unspecified site

411.0

 

Post myocardial infarction syndrome

411.1

 

Intermediate coronary syndrome

411.81

 

Acute coronary occlusion without myocardial infarction

411.89

 

 

412

 

Old myocardial infarction

413.0-413.1

 

Angina pectoris

413.9

 

Other and unspecified angina pectoris

414.00-414.05

 

Coronary atherosclerosis

414.06

 

Of native coronary artery of transplanted heart

414.07

 

Of bypass graft (artery) (vein) of transplanted heart

414.8-414.9

 

 

415.11

 

Iatrogenic pulmonary embolism and infarction

415.19

 

 

416.0

 

Primary pulmonary hypertension

416.8

 

Other chronic pulmonary heart diseases

423.2

 

Constrictive pericarditis

423.9

 

Unspecified disease of pericardium

424.0-424.3

 

Valve disorders

425.0-425.5

 

Cardiomyopathy

425.7-425.9

 

 

428.0

 

Congestive heart failure, unspecified

428.1

 

Left heart failure

428.20

 

Systolic heart failure, unspecified

428.21

 

Systolic heart failure, acute

428.22

 

Systolic heart failure, chronic

428.23

 

Systolic heart failure, acute or chronic

428.30

 

Diastolic heart failure, unspecified

428.31

 

Diastolic heart failure, acute

428.32

 

Diastolic heart failure, chronic

428.33

 

Diastolic heart failure, acute or chronic

428.40

 

Combined systolic and diastolic heart failure, unspecified

428.41

 

Combined systolic and diastolic heart failure, acute

428.42

 

Combined systolic and diastolic heart failure, chronic

428.43

 

Combined systolic and diastolic heart failure, acute or chronic

428.9

 

Heart failure, unspecified

429.71

 

Acquired cardiac septal defect

674.50

 

Peripartum cardiomyopathy, unspecified as to episode of care or not applicable

674.51

 

Peripartum cardiomyopathy, delivered, with or without mention of antepartum condition

674.52

 

Peripartum cardiomyopathy, delivered, with mention of postpartum condition

674.53

 

Peripartum cardiomyopathy, antepartum condition or complication

674.54

 

Peripartum cardiomyopathy, postpartum condition or complication

745.4

 

Ventricular septal defect

745.5

 

Ostium secundum type atrial septal defect

V12.50

 

Unspecified circulatory disease

V12.51

 

Personal history of venous thrombosis and embolism

V42.1

 

Organ or tissue replaced by transplant, heart

V42.2

 

Organ or tissue replaced by transplant, heart valve

V43.21

 

Heart assist device

V43.22

 

Fully implantable artificial heart

V43.3

 

Organ or tissue replaced by transplant, other means, heart valve

V45.81

 

Other post surgical status, aortocoronary bypass

V45.82

 

Other post surgical status, percutaneous transluminal coronary

 

 

angioplasty

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity”, section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

  • The medical record does not document that the service described by the HCPCS code was provided.
  • The service was provided for an indication not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.
  • The service does not follow the guidelines of this policy.
  • The documentation in the medical record does not support the medical necessity of providing this service.
  • The service is for screening purposes.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

  • Diagnosis (diagnoses) must be present on the submitted claim, and be coded to the highest level of specificity to accurately represent the patient's condition
  • The service(s) should be reported using the appropriate HCPCS code(s) and revenue code
  • Refer to the Correct Coding Initiative for "bundling" information
  • Coverage criteria must be met for these services to be reimbursed by Medicare.
  • The diagnosis code(s) must be representative of the patient's condition.
  • If an injection code procedure is performed during a cardiac catheterization, the facility should bill the cardiac catheterization code, one or more of the injection codes, and the corresponding Supervision and Interpretation code.
  • Each injection code has only one corresponding Supervision and Interpretation code. Multiple injection procedures may be performed during a cardiac catheterization. When this occurs, hospitals should bill all of the applicable injection codes, but report each of the applicable Supervision and Interpretation codes (93555 and /or 93556) only once on a bill. Both codes, 93555 and 93556 may be reported on the same bill as long as each code is reported only once, regardless of the number of injection procedures performed.

Documentation Requirements

  • Documentation supporting the medical necessity for this procedure should be legible, maintained in the patient's medical record, and available to Medicare upon request.

Utilization Guidelines

N/A

Other Comments

Financial Responsibility:

Provider Liable

The provider of the service or the ordering physician must have notified the patient in writing, prior to the service, and obtained a signature verifying Advance Beneficiary Notice. Without prior notice, services denied as not medically necessary cannot be billed to the beneficiary. The provider is liable.

Beneficiary Liable

If there is clear evidence that the beneficiary was issued and signed an Advanced Beneficiary Notice (ABN) prior to the service, the liability rests with the beneficiary. Claims for dates of service prior to January 1, 2003 should contain the condition code 20 and occurrence code 32, with date to signify that an ABN was issued to the beneficiary. Absence of these codes will result in a provider liable determination

Claims for dates of service beginning January 1, 2003 should contain the occurrence code 32 with date to signify that an ABN was issued to the beneficiary. Absence of this code will result in a provider liable determination.

Reference: PM AB-02-168, CR 2415

Sources of Information and Basis for Decision

·        TrailBlazer Medicare B Newsletters:

·         No. 020, October 3, 1997

·         No. 021, November 30, 1997

·         No. 029, November 30, 1998

·         No. 030 February 10, 1999

·         No. 033, June 15, 1999

·         No. 02-027, June 28/2002

  • Annual ICD-9-CM Updates for FY 2004. Program Memorandum AB 03-091, Change Request 2763

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

Advisory Committee Meeting Date:

 

Start Date of Comment Period

03/26/1999

End Date of Comment Period

05/10/1999

Start Date of Notice Period

07/28/1999

Revision History

Number

 

Date

 

Change

99-05 R4

 

10/01/2003

 

Annual update of ICD-9 codes.  New limited coverage for codes 93501, 93526-93533, and

 

 

 

 

93541-93542: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, and 404.93.

 

 

 

 

New limited coverage for codes 93510-93511, 93514, 93524, 93539, 93540, 93543, 93544,

 

 

 

 

3545, 93555, 93556: 414.06 (revise), 414.07 (new), V43.21, V43.22, and deleted V43.2. 

 

 

 

 

(PM AB 03-091, CR 2763).  The following ICD-9 codes have

 

 

 

 

been included in all the CPT/HCPCS groupings in this policy, 674.50-674.54.  .

 

 

 

 

Descriptors shortened for HCPCS/CPT codes

99-05-R3

 

10/01/2002

 

Addition of new ICD-9 codes per annual update.

99-05-R2

 

09/12/2001

 

Expanded coverage for HCPCS codes 93543, 93555, and 93556. See Provider

 

 

 

 

Bulletin 09/12/2001 for specific changes. Placed in new format and CPT descriptors shortened

99-05-R1

 

11/17/2000

 

Limited coverage expanded to maintain consistency in policies between the intermediary and

 

 

 

 

the carrier. See 11/17/2000 Provider Bulletin for specific changes.

 

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.