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Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L770

LCD Title

Cardiovascular Stress Testing

Contractor's Determination Number

00-04-R4

AMA/CPT and ADA/CDT 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. CDT-4 codes and descriptions are © 2004 American Dental Association. All rights reserved.

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

Oversight Region

Region III

CMS Consortium

Northeast

DMERC Region LCD Covers

N/A

Original Determination Effective Date

06/26/2000

Original Determination Ending Date 

 

Revision Effective Date

09/01/2004

10/01/2003

01/24/2003

10/01/2002

Revision Ending Date

 

Indications and Limitations of Coverage and/or Medical Necessity

Description

Cardiovascular stress testing includes non-invasive diagnostic tests, which are useful in the evaluation of patients for several types of heart disease.  Cardiovascular stress testing utilizes cardiac physiological monitoring (including EKG, B/P, HR, etc) during and after stress, with or without subsequent cardiac imaging (such as echocardiography or nuclear cardiac imaging). A diseased heart responds abnormally, allowing the physician monitoring the test to make a diagnostic determination.

Exercise stress testing is considered the standard of care for most patients when cardiovascular stress testing is indicated.  Exercise may be in the form of a treadmill, bicycle, or other exercise method. Pharmacologic agents may be used in lieu of exercise in selected clinical circumstances. Pharmacologic agents typically utilized for cardiovascular stress testing include Adenosine, Dobutamine, Dipyramidole and Arbutamine.

Cardiovascular stress testing is considered adjunctive to the history and physical examination in the diagnosis and treatment of the patient who has known or suspected heart disease.

Indications

Covered indications for cardiovascular stress testing include the following:

  • Evaluation of patients with signs or symptoms or Coronary Artery Disease(CAD),
  • Evaluation of the prognosis and/or severity of known CAD, valvular, congenital, and/or myocardial disease,
  • Evaluation of functional capacity in persons with known CAD, valvular, congenital, and/or myocardial disease,
  • Evaluation of the effects of therapy/interventions in persons with CAD, valvular, congenital and/or myocardial disease,
  • Evaluation and exercise prescription for patients entering cardiac rehabilitation,
  • Evaluation of patients with known or suspected exercise-induced arrhythmias, and;
  • Identification of appropriate settings in patients with rate-adaptive pacemakers.

Pharmacologic cardiovascular stress testing is indicated when the patient is unable to exercise adequately. Documentation in the patient's record must clearly indicate why the patient cannot undergo exercise stress testing.

Pharmacologic stress testing may not be used to determine functional capacity or cardiac exercise prescription.

When cardiovascular stress testing is performed in conjunction with other cardiac diagnostic tests (including echocardiography and nuclear medicine studies), the general rules of this policy apply. For details of coverage of those other cardiac diagnostic tests, refer to their specific coverage policies. Only the most appropriate test(s) necessary to determine information should be performed.

Cardiac stress testing must be performed with the physician actually present during the entire procedure.

Coverage Topic

Diagnostic Tests and X-Rays

Bill Type Codes

11X, 12X, 18X, 21X (No HCPCS code required)

13X, 14X, 71X, 85X (HCPCS code required)

Revenue Codes

HCPCS codes 93015, 93016, or 93017 may be billed with revenue code 482, and;

HCPCS code J0150, J0395, J1245, or J1250 may be billed with the following revenue code

  • 250 for bill types 11X, 12X, 18X, 21X, and;
  • 636 for bill types 13X, 14X, 71X, 85X

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:

93015

© 

Cardiovascular Stress Test

93016

©

Cardiovascular Stress Test

93017

©

Cardiovascular Stress Test

93018

©

Cardiovascular Stress Test

J0152

 

Injection, Adenosine, 30 mg

J0395

 

Injection, Arbutamine HCl, 1 mg

J1245

 

Injection Dipyridamole, per 10 mg

J1250

 

Injection, Dobutamine, per 250 mg

J3490

 

Unclassified drug

© CPT American Medical Association

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.

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

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

411.0

 

Post myocardial infarction syndrome

411.1

 

Intermediate coronary syndrome

411.81

 

Acute coronary occlusion without myocardial infarction

411.89

 

 

413.0-413.1

 

Angina pectoris

413.9

 

Other and unspecified angina pectoris

414.00-414.05

 

Coronary atherosclerosis

414.06

 

Of coronary artery of transplanted heart

414.10

 

Aneurysm of heart (wall)

414.11

 

Aneurysm of coronary vessels

414.12

 

Dissection of coronary artery

414.19

 

Of aneurysm of heart

414.8

 

Other specified forms of chronic ischemic heart disease

 

 

Note: Use this code to report those patients with a strong clinical

 

 

suspicion of silent ischemia

424.0-424.3

 

Valve disorders

424.0-425.5

 

Cardiomyopathy

425.7-425.9

 

 

426.0

 

Atrioventricular block, complete

426.12-426.13

 

Mobitz (type)II and other second degree atrioventricular block

426.2-426.4

 

Bundle branch block; left hemiblock, left other, right bundle branch

426.50-426.54

 

Bundle branch block, other and unspecified

426.6

 

Other heart block

427.1

 

Paroxysmal ventricular tachycardia

427.31-427.32

 

Atrial fibrillation and flutter

427.41-427.42

 

Ventricular fibrillation and flutter

427.69

 

Ventricular premature beats

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

 

 

429.2

 

Cardiovascular disease, unspecified

429.5-429.6

 

Ill-defined descriptions and complications of heart disease

429.71

 

Acquired cardiac septal defect

429.81

 

Other disorders of papillary muscle

780.2

 

Syncope and collapse

786.02

 

Orthopnea

786.05

 

Shortness of breath

786.09

 

 

789.50-786.51

 

Chest pain

794.31

 

Abnormal electrocardiogram

996.72

 

Other complications of cardiac device or graft

996.83

 

Complications of transplanted heart

V15.1

 

Personal history of surgery to heart and great vessels

V42.1

 

Heart replaced by transplant

V42.2

 

Heart valve replaced by transplant

V42.6

 

Lung replaced by transplant

V43.3

 

Heart valve replaced by other means

V45.01

 

Post surgical status: cardiac pacemaker

 

 

Note: Use this diagnosis code only for the rate-adaptive pacemakers

V45.81-V45.82

 

Postsurgical status: aortocoronary bypass and percutaneous

 

 

transluminal coronary angioplasty status

V72.81

 

Preoperative cardiovascular examination (Note: Use this diagnosis

 

 

code only for high-risk patients and high-risk surgeries.)

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.

Documentation Requirements

  • Documentation in the patient’s medical record must indicate that the entire procedure was either performed by the physician or under the physician’s direct personal supervision.  NOTE: Direct personal supervision means that the physician must be physically present in the same office suite and immediately available to provide assistance and direction throughout the test.
  • Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and available to Medicare upon request.
  • The medical necessity for the procedure must be documented in the patient’s medical record.
  • When repeating stress tests, the medical record documentation must identify separate clinical indications, regardless of the ICD-9-CM code submitted for the test.

Appendices

N/A

Utilization Guidelines

·        Medicare will monitor the utilization of this procedure through the Medical Review process.

·        The drugs referenced in the “HCPCS Code(s)” and “Indications and Limitations of Coverage” sections of this policy may be used for indications other than pharmacological stress agents with cardiovascular testing.  The use of these drugs is not subject to the list of diagnoses listed in the “ICD-9-CM Codes that Support Medical Necessity: section of this policy.  The indications for the use of these drugs must be documented in the patient's medical record as well as the appropriateICD-9-CM code that describes the patient’s condition.

·        Stress testing should be conducted by well-trained personnel.  Only technicians and physicians familiar with normal and abnormal responses during exercise can recognize or prevent untoward events.  Equipment, medications, and personnel trained to provide cardiopulmonary resuscitation (CPR) must be readily available.

Sources of Information and Basis for Decision

·        TrailBlazer, Part B newsletters, No. 033, June 15, 1999, and No. 028 October 9, 1998

·        Texas Medicare Part A newsletter, No. 3-98, October 22, 1998

·        Wisconsin Medicare Part B Carrier-Local Medical Review Policy

·        Xact Medicare Part B Carrier-Local Medical Review Policy

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).

Start Date of Comment Period

04/05/2000

End Date of Comment Period

05/05/2000

Start Date of Notice Period

05/26/2000

Revision History Number

R4

R3

R2

R1

Revision History Explanation

Number

 

Date

 

Change

R4

 

09/01/2004

 

J0151 deleted for 2004. Added J 0152 and J0395.

 

 

 

 

Converted from LMRP to LCD format.

R3

 

10/01/2003

 

Spelling errors corrected.

R2

 

01/24/2003

 

CPT descriptors changed to short descriptor.

R1

 

10/01/2002

 

Addition of new ICD-9 codes per annual update.

 

 

 

 

 See bulletin on website for specifics.

 

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.