Echocardiography

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Contractor Name

CareFirst of Maryland INC., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LCD Database ID Number

L12914

LCD Title

Echocardiography

Contractor's Determination Number

03-03-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 ©2002 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.

· Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.

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

06/27/2003

Revision Effective Date

03/09/2005

11/01/2004

10/01/2004

10/01/2003

Indications and Limitations of Coverage and/or Medical Necessity

Description

Echocardiography is a non-invasive technique where pulsed high frequency sound waves are used to locate and study the movements and dimensions of cardiac structures. The sound waves track the motion of the cardiac structures over a period of time.

According to the American College of Cardiology and the American Heart Association (ACC/AHA), while cardiac ultrasound may be applied in different forms (M-mode, two- dimensional, spectral and color flow Doppler imaging), and by two different approaches (transthoracic, transesophageal), all are encompassed in the term echocardiography.

Indications and Limitations

Echocardiography is performed to evaluate specific cardiovascular disorders and for evaluating signs and/or symptoms which may be related to a cardiac disorder. Indications are defined for Transthoracic Echocardiography (TTE) and Transesophageal Echocardiography (TEE).

Ventricular Function and Cardiomyopathies
TTE can measure and record changes in myocardial thickness (hypertrophy and thinning), changes in chamber volume and form, and define limits of contractility. TTE can measure the response to volume changes following chronic excessive pressure and/or therapeutic interventions, as well as recognize myocardial and valvular function changes. TTE serves as a diagnostic aid to classify myopathies as hypertrophic, dilated or restrictive. Normal systolic function and/or ventricular hypertrophy in individuals with signs and/or symptoms suggestive of ventricular dysfunction may suggest the presence of diastolic functional abnormalities.

TTE is only one method for evaluating ventricular function. Alternative methods include left ventricular angiography (from cardiac catheterization), gated blood pool scans (from nuclear cardiology), and some of the newer CT and MRI techniques. In most cases, only one method of assessment is needed and this should be the most cost-effective method to answer the clinical question being investigated. TTE assessment of left ventricular function is generally considered preferable to TEE.

Hypertensive Cardiovascular Disease
TTE may be indicated in individuals with hypertension who have clinical evidence of heart disease. TTE may monitor changes in the left ventricle which might indicate the need for long-term antihypertensive therapy.

Acute Myocardial Infarction and Coronary Insufficiency
TTE may detect myocardial ischemia and/or complications of acute infarction such as ventricular dysfunction, mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture.

Exposure to Cardiotoxic Agents (Chemotherapeutic and External)
TTE is used to monitor changes in myocardial contractility for patients during treatment with therapeutic agents with known myocardial toxicity. Examples of such agents include, but are not limited to Doxorubicin, Rubramycin, and Adriamycin. TTE may be indicated in selected patients who are expected to receive, or have received, such cardiotoxic chemotherapeutic agents.

It is not expected that all patients who undergo treatment with such drugs will receive echocardiography. Payment for echocardiography for persons receiving chemotherapy is limited to the following patients:

Patients who have developed signs and/or symptoms of cardiac toxicity
Patients with known or suspected compromise of cardiac function prior to treatment with such drugs in whom further deterioration of function due to chemotherapy is anticipated.
Patients with known or suspected compromise of cardiac function prior to treatment with such drugs for whom the choice of chemotherapeutic agents will potentially be influenced by the outcome of the echocardiogram.
Patients who are expected to receive certain chemotherapeutic agents that are known to be especially toxic when given in combination.

Cardiac Transplant and Rejection Monitoring
TTE evaluation is an integral part of the cardiac donor selection and donor recipient matching process by monitoring ventricular function and valvular performance.

TTE will determine myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics, and the late development of pericardial fluid which may indicate possible rejection.

Intraoperative TEE is appropriate in heart-lung transplants where the integrity and morphology of the pulmonary vascular anastomoses are critical. Routine TEE for patients undergoing cardiopulmonary bypass is not supportable.

Native Valvular Heart Disease
TTE is the appropriate technique for evaluation of valvular pathology. The image created by TTE defines the valve and valvular apparatus which provides information for therapeutic options, especially interventions for mitral stenosis. Serial assessment by non-invasive TTE is preferable to serial assessment by relatively invasive TEE. However, TEE may be indicated prior to planned valvular repair surgery to more precisely determine the valvular anatomy and also during the actual surgical procedure to repair the valve or valves.

Prosthetic Heart Valves (Mechanical and Bio-Prostheses)

TTE provides diagnostic functional information for valvular pathology and may be indicated after a prosthetic valve implant to define the size, position, underlying ventricular function and concomitant valve pathologies. In some patients, acoustical shadowing may affect data acquisition. TEE is appropriately considered when prosthetic dysfunction is suspected or therapeutic decisions are pivotal and data is inconclusive. TEE is not routinely indicated in all patients with prosthetic valves.

Acute Endocarditis
TTE provides diagnostic information pertaining to valvular pathology, the infective process and ventricular function. TTE affords non-invasive serial assessment and is generally better able to define the consequences of the infective valvular process on ventricular function. A TEE may be medically necessary to provide supplemental diagnostic information following a TTE if therapeutically relevant, e.g., when the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology) and TTE does not document endocarditis, TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae).

Pericardial Disease
TTE can demonstrate the hemodynamic consequences of pericardial fluid accumulation on cardiac motion and blood flow patterns. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. TTE lacks the necessary specificity and sensitivity to be reliable in the detection of chronic pericardial constriction. TEE does not provide any additional information above that which is provided by TTE in the assessment and management of pericardial pathology.

Aortic Pathology
TTE can provide valuable information when acute or chronic aortic pathology is present. TTE is indicated for investigation of aortic ulceration, atherosclerotic plaque and mural thrombotic material. TEE may be appropriate to search for and define remediable aortic lesions if embolic episodes are repetitive and focused aortic surgical intervention is contemplated. Because of the posterior position of the thoracic aorta and the image span of the TEE window, the TEE is a more definitive study of aortic dissection and aneurysm than TTE. In suspected aortic trauma or dissection, the application of bedside TEE is frequently considered the diagnostic study of choice.

Congenital Heart Disease
TTE provides accurate anatomic definition of most congenital heart disease in children and small adults. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and non-invasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. In postoperative patients with fibrosis, echo opaque patches and prostheses, TTE may produce incomplete data due to inadequate penetration and acoustical shadowing. When TTE is technically inadequate or anatomic definition incomplete, TEE may be considered.

Suspected Cardiac Thrombi and Embolic Sources
TTE is particularly sensitive in the detection of ventricular thrombi and potential embolic material. Limited visualization of the atria render TTE less sensitive in the detection of atrial thrombus, therefore, TEE may be preferred. In patients with cardiac pathology associated with a high incidence of thromboembolism (valvular heart disease, arrhythmias - especially atrial fibrillation, cardiomyopathies and other causes of ventricular dysfunction), the information provided by TEE must have therapeutic relevance to alter therapy or change the clinical outcome to support medical necessity. A negative TTE or TEE examination does not exclude a cardiac embolus and the finding of thrombus or vegetation does not establish a cardiac embolic source.

Cardiac Tumors and Masses
TTE can visualize, assess and measure infiltrative and ventricular tumors and masses of the right atrium. TEE provides a more detailed view of the left atrium and is more sensitive in defining mass characteristics (solid, cystic, etc.) extensions and attachments.

Critically Ill and Trauma Patients
Echocardiography is appropriate for the management of critically ill patients. When TTE fails to provide adequate visualization (COPD, ventilator patient), TEE may provide diagnostic information and affect treatment management. A persistent unexplained fever, a reasonable probability of remediable aortic, cardiac or central pulmonary vascular pathology or inadequately defined volume status is among the accepted indications for echocardiography.

Coverage Topic

Diagnostic Tests and X-Rays
Outpatient Hospital Services

Bill Type Codes

13X, 14X

Revenue Codes

48X

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:

93303	©	Echo transthoracic
93304	©	Echo transthoracic
93307	©	Echo exam of heart
93308	©	Echo exam of heart
93312	©	Echo transesophageal
93313	©	Echo transesophageal
93314	©	Echo transesophageal
93315	©	Echo transesophageal
93316	©	Echo transesophageal
93317	©	Echo transesophageal
93318	©	Echo transesophageal intraop
93320	©	Doppler echo exam, heart
93321	©	Doppler echo exam, heart
93325	©	Doppler color flow add-on

Does the “CPT 30% Coding Rule” Apply?

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 HCPCS codes 93303, 93304, 93315, 93316, and 93317:

Covered for:

745.0		Bulbus cordis anomalies and anomalies of cardiac septal closure,
		common truncus
745.10		Complete transposition of great vessels
745.11		Double outlet right ventricle
745.12		Transposition of great vessels
745.19		Other transposition of great vessels
745.2		Tetralogy of Fallot
745.3		Common ventricle
745.4		Ventricular septal defect
745.5		Other cardiac defects
745.60		Endocardial cushion defect, unspecified type
745.61		Endocardial cushion defects, ostium primum defect
745.69		Other congenital endocardial cushion defect
745.7		Cor biloculare
745.8		Other anomalies
745.9		Unspecified congenital anomalies of the heart
746.00		Pulmonary valve anomaly, unspecified
746.01		Atresia congenital
746.02		Stenosis, congenital
746.09		Other congenital anomalies of pulmonary valve
746.1		Tricuspid atresia and stenosis, congenital
746.2		Ebstein's anomaly
746.3		Congenital stenosis of aortic valve
746.4		Congenital insufficiency of aortic valve
746.5		Congenital mitral stenosis
746.6		Congenital mitral insufficiency
746.7		Hypoplastic left heart syndrome
746.81		Subaortic stenosis
746.82		Cor triatriatum
746.83		Infundibular pulmonic stenosis
746.84		Obstructive anomalies of heart, not elsewhere classified
746.85		Coronary artery anomaly
746.87		Congenital malposition of heart and cardiac apex
746.89		Other specified congenital anomaly of heart
747.0		Patent ductus arteriosus
747.10		Coarctation of aorta (preductal) (postductal)
747.11		Interruption of aortic arch
747.20		Anomaly of aorta, unspecified
747.21		Anomalies of aortic arch
747.22		Atresia and stenosis of aorta
747.29		Other congenital anomaly of aorta
747.3		Congenital anomalies of pulmonary artery
747.40		Anomaly of great veins, unspecified
747.41		Total anomalous pulmonary venous connection
747.42		Partial anomalous pulmonary venous connection
747.49		Other congenital anomalies of great veins
759.3		Situs inversus
759.82		Marfan syndrome

Medicare is establishing the following limited coverage for codes 93307, 93308, 93320, 93321, and 93325:

Covered for:

074.21		Coxsackie pericarditis
074.22		Coxsackie endocarditis
074.3		Hand, foot, and mouth disease
086.0		Chagas' disease with heart involvement
088.81		Lyme disease
093.0		Cardiovascular syphilis, aneurysm or aorta, specified as syphilitic
093.1		Cardiovascular syphilis, syphilitic aortitis
093.21		Cardiovascular syphilis, syphilitic endocarditis, mitral valve
093.22		Cardiovascular syphilis, syphilitic endocarditis, aortic valve
093.23		Cardiovascular syphilis, syphilitic endocarditis, tricuspid valve
093.24		Cardiovascular syphilis, syphilitic endocarditis, pulmonary valve
093.81		Cardiovascular syphilis, syphilitic pericarditis
093.82		Cardiovascular syphilis,, syphilitic myocarditis
098.84		Gonococcal endocarditis
112.81		Candidal endocarditis
115.03		Infection by histoplasma capsulatum, pericarditis
115.04		Infection by histoplasma capsulatum, endocarditis
115.13		Infection by histoplasma duboisii, pericarditis
115.14		Infection by histoplasma duboisii, endocarditis
130.3		Myocarditis due to toxoplasmosis
135		Sarcoidosis
164.1		Malignant neoplasm of heart
198.8		Secondary malignant neoplasm of other specified sites
212.7		Benign neoplasm of heart
238.8		Neoplasm of uncertain behavior of other specified sites
239.8		Neoplasm of unspecified nature of other specified sites
275.0		Disorders of iron metabolism
276.5		Volume depletion
277.3		Amyloidosis
391.0		Acute rheumatic pericarditis
391.1		Acute rheumatic endocarditis
391.2		Acute rheumatic myocarditis
391.8		Other acute rheumatic heart disease
392.0		Rheumatic chorea with heart involvement
393		Chronic rheumatic pericarditis
394.0		Mitral stenosis
394.1		Rheumatic mitral insufficiency
394.2		Mitral stenosis with insufficiency
395.0		Rheumatic aortic stenosis
395.1		Rheumatic aortic insufficiency
395.2		Rheumatic stenosis with insufficiency
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		Multiple involvement of mitral and aortic valves
397.0		Diseases of tricuspid valve
397.1		Rheumatic diseases of pulmonary valve
398.0		Rheumatic myocarditis
398.91		Rheumatic heart failure (congestive)
401.0		Essential hypertension, malignant
402.00		Malignant hypertensive heart disease without heart failure
402.10		Benign hypertensive heart disease without heart failure
402.90		Unspecified hypertensive heart disease without heart failure
404.00		Malignant hypertensive heart and renal disease without mention of heart
		failure or renal failure
404.10		Benign hypertensive heart and renal disease without mention of heart
		failure or renal failure
404.90		Unspecified hypertensive heart and renal disease without mention of heart
		failure or renal failure
405.01		Secondary renovascular hypertension, malignant
410.00		Acute myocardial infarction; of anterolateral wall, episode of care
		unspecified
410.01		Acute myocardial infarction, of anterolateral wall, initial episode of care
410.02		Acute myocardial infarction, of anterolateral wall, subsequent episode of
		care
410.10		Acute myocardial infarction, of other anterior wall, episode of care
		unspecified
410.11		Acute myocardial infarction, of other anterior wall, initial episode of care
410.12		Acute myocardial infarction, of other anterior wall, subsequent episode of
		care
410.20		Acute myocardial infarction, of inferolateral wall, episode of care
		unspecified
410.21		Acute myocardial infarction, of inferolateral wall, initial episode of care
410.22		Acute myocardial infarction, of inferolateral wall, subsequent episode of
		care
410.30		Acute myocardial infarction of inferoposterior wall, episode of care
		unspecified
410.31		Acute myocardial infarction of inferoposterior wall, initial episode of care
410.32		Acute myocardial infarction of inferoposterior wall, subsequent episode
		of care
410.40		Acute myocardial infarction of other inferior wall, episode of care
		unspecified
410.41		Acute myocardial infarction of other inferior wall, initial episode of care
410.42		Acute myocardial infarction of other inferior wall, subsequent episode of
		care
410.50		Acute myocardial infarction of other lateral wall, episode of care
		unspecified
410.51		Acute myocardial infarction of other lateral wall, initial episode of care
410.52		Acute myocardial infarction of other lateral wall, subsequent episode of
		care
410.60		Acute myocardial infarction of posterior wall, episode of care unspecified
410.61		Acute myocardial infarction of posterior wall, initial episode of care
410.62		Acute myocardial infarction of posterior wall, episode of care unspecified
410.70		Acute myocardial infarction, subendocardial infarction, subsequent
		episode of care
410.71		Acute myocardial infarction, subendocardial infarction, initial episode of
		care
410.72		Acute myocardial infarction, subendocardial infarction, subsequent
		episode of care
410.80		Acute myocardial infarction of other specified sites, episode of care
		unspecified
410.81		Acute myocardial infarction of other specified sites, initial episode of care
410.82		Acute myocardial infarction of other specified sites, subsequent episode
		of care
411.0		Postmyocardial infarction syndrome
411.1		Intermediate coronary syndrome
411.81		Coronary occlusion without myocardial infarction
411.89		Other acute and subacute form of ischemic heart disease
413.0		Angina decubitus
413.1		Prinzmetal angina
413.9		Other and unspecified angina pectoris
414.00		Coronary atherosclerosis, of unspecified type of vessel, native or graft
414.01		Coronary atherosclerosis, of native coronary artery
414.02		Coronary atherosclerosis, of autologous vein bypass graft
414.03		Coronary atherosclerosis, of nonautologous biological bypass graft
414.05		Coronary atherosclerosis, of artery bypass graft
414.06		Coronary atherosclerosis, of native coronary artery of transplanted heart
414.07		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
414.8		Other specified forms of chronic ischemic
415.0		Acute cor pulmonale
415.11		Iatrogenic pulmonary embolism and infarction
416.0		Primary pulmonary hypertension
416.8		Other chronic pulmonary heart diseases
420.0		Acute pericarditis in diseases classified elsewhere
420.90		Acute pericarditis, unspecified
421.0		Acute and subacute bacterial endocarditis
421.1		Acute and subacute infective endocarditis in diseases classified elsewhere
421.9		Unspecified acute endocarditis
422.0		Acute myocarditis in diseases classified elsewhere
422.91		Idiopathic myocarditis
422.92		Septic myocarditis
422.93		Other and unspecified myocarditis
423.0		Hemopericardium
423.1		Adhesive pericarditis
423.2		Constrictive pericarditis
423.8		Other specified diseases of pericardium
423.9		Unspecified disease of pericardium
424.0		Mitral valve disorders
424.1		Aortic valve disorders
424.2		Tricuspid valve disorders
424.3		Pulmonary valve disorders
424.90		Endocarditis, valve, unspecified, unspecified cause
424.91		Endocarditis in diseases classified elsewhere
424.99		Other endocarditis, valve unspecified
425.0		Endomyocardial fibrosis
425.1		Hypertrophic obstructive cardiomyopathy
425.2		Obscure cardiomyopathy of Africa
425.3		Endocardial fibroelastosis
425.4		Other primary cardiomyopathies
425.5		Alcoholic cardiomyopathy
425.7		Nutritional and metabolic cardiomyopathy
425.8		Cardiomyopathy in other diseases classified elsewhere
427.31		Atrial fibrillation
427.32		Atrial flutter
428.0		Congestive heart failure
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
429.0		Myocarditis, unspecified
429.1		Myocardial degeneration
429.2		Cardiovascular disease, unspecified
429.3		Cardiomegaly
429.4		Functional disturbances following cardiac surgery
429.5		Rupture of chordae tendineae
429.6		Rupture of papillary muscle
429.71		Acquired cardiac septal defect
429.79		Other certain sequelae of myocardial infarction, not elsewhere classified
429.81		Other disorders of papillary muscle
434.10		Cerebral embolism without mention of cerebral infarction
434.11		Cerebral embolism with cerebral infarction
434.90		Cerebral artery occlusion, unspecified, without
		mention of cerebral infarction
434.91		Cerebral artery occlusion, unspecified, with cerebral infarction
435.8		Other specified transient cerebral ischemias
435.9		Unspecified transient cerebral ischemia
440.20		Atherosclerosis of native arteries of the extremities, unspecified
441.00		Dissection of aorta, unspecified site
441.01		Dissecting aortic, thoracic
441.03		Dissecting aortic, thoracoabdominal
441.1		Thoracic aneurysm, ruptured
441.2		Thoracic aneurysm, without mention of rupture
441.6		Thoracoabdominal aneurysm, ruptured
441.7		Thoracoabdominal aneurysm, without mention of rupture
444.0		Arterial embolism and thrombosis of abdominal aorta
444.1		Arterial embolism and thrombosis of thoracic aorta
444.21		Arterial embolism and thrombosis, upper extremity
444.22		Arterial embolism and thrombosis, lower extremity
444.81		Arterial embolism and thrombosis, iliac artery
444.89		Arterial embolism and thrombosis, other
444.9		Arterial embolism and thrombosis, unspecified artery
446.1		Acute febrile Mucocutaneous Lymph Node Syndrome (MCLS)
446.7		Takayasu’s disease
458.0		Orthostatic hypotension
518.4		Acute edema of lung
518.5		Pulmonary insufficiency following trauma and surgery
518.82		Other pulmonary insufficiency, not elsewhere classified
518.83		Chronic respiratory failure
518.84		Acute and chronic respiratory failure
674.50		Peripartum cardiomyopathy, unspecified as to episode of care or not
		applicable
674.51		Peripartum cardiomyopathy, delivered, with or without mention of x
		applicable
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
674.82		Other complication of puerperium, with delivery, with mention of
		postpartum complication
674.84		Other complication of puerperium, postpartum condition or complication
710.0		Systemic lupus erythematosus
746.2		Other congenital anomalies of heart, Ebstein’s anomaly
746.3		Other congenital anomalies of heart, congenital stenosis of aortic valve
746.4		Other congenital anomalies of heart, congenital insufficiency of aortic
		valve
746.5		Other congenital anomalies of heart, congenital mitral stenosis
746.6		Other congenital anomalies of heart, congenital mitral insufficiency
746.7		Other congenital anomalies of heart, hypoplastic left heart syndrome
746.81		Subaortic stenosis
746.82		Cor triatriatum
746.83		Infundibular pulmonic stenosis
746.84		Obstructive pulmonic stenosis
746.85		Coronary artery anomaly
746.86		Congenital heart block
746.87		Malposition of heart and cardiac apex
746.89		Other specified congenital anomaly of heart
747.0		Patent ductus arteriosus
747.10		Coarctation of aorta
747.11		Interruption of aortic arch
747.20		Anomaly of aorta, unspecified
747.21		Anomalies of aortic arch
747.22		Atresia and stenosis of aorta
747.29		Other congenital anomaly of aorta
747.3		Congenital anomalies of pulmonary artery
747.40		Anomaly of great veins, unspecified
747.41		Total anomalous pulmonary venous connection
747.42		Partial anomalous pulmonary venous connection
747.49		Other congenital anomalies of great veins
759.3		Situs inversus
759.82		Marfan syndrome
780.2		Syncope and collapse
780.6		Fever
785.2		Undiagnosed cardiac murmurs
785.3		Other abnormal heart sounds
785.50		Shock, unspecified
785.51		Cardiogenic shock
785.59		Other shock without mention of trauma
786.50		Chest pain, unspecified
786.59		Chest pain, other
790.7		Bacteremia
807.4		Flail chest
861.01		Injury to heart without mention of open wound into thorax, contusion
861.02		Injury to heart without mention of open wound into thorax, laceration
		without penetration of heart chambers
861.03		Injury to heart without mention of open wound into thorax, with
		penetration of heart chambers
861.11		Injury to heart with open wound into thorax, contusion
861.12		Injury to heart with open wound into thorax, laceration without
		penetration of heart chambers
861.13		Injury to heart with open wound into thorax, with penetration of heart
		chambers
901.0		Thoracic aorta injury
901.2		Superior vena cava injury
901.41		Injury to pulmonary artery
901.42		Injury to pulmonary vein
958.0		Early complication of trauma, air embolism
958.1		Early complication of trauma, fat embolism
958.4		Traumatic shock
960.7		Poisoning by antineoplastic antibiotics
962.0		Poisoning by adrenal cortical steroids
963.1		Poisoning by antineoplastic and immunosuppressive drugs
965.09		Poisoning by opiates and related narcotics, other
980.3		Toxic effect of fusel oil
986		Toxic effect of carbon monoxide
990		Effects of radiation, unspecified
994.0		Effects of lightning
994.8		Electrocution and nonfatal effects of electric current
995.1		Angioneurotic edema not elsewhere classified
996.01		Mechanical complication of cardiac device, implant and graft, due to
		cardiac pacemaker (electrode)
996.02		Mechanical complication of cardiac device, implant and graft, due to
		heart valve prosthesis
996.04		Mechanical complication due to automatic implantable cardiac
		defibrillator
996.61		Infection and inflammatory reaction due to cardiac device, implant, and
		graft
996.71		Other complications due to heart valve prosthesis
996.83		Complications of transplanted heart
997.1		Cardiac complications
998.0		Postoperative shock, not elsewhere classified
998.51		Infected postoperative seroma
999.3		Complications due to medical care, other infection
999.4		Complications due to medical care, anaphylactic shock due to serum
V42.1		Heart replaced by transplant
V42.2		Heart valve replaced by transplant
V43.3		Heart valve replaced by other means
V58.1		Encounter for other and unspecified procedures and after care,
		chemotherapy
V58.69		Encounter for other and unspecified procedures and after care, long term
		(current) use of other medications
V58.83		Encounter for other and unspecified procedures and after care, encounter
		for therapeutic drug monitoring
V59.8		Donor of other specified organ or tissue

Medicare is establishing the following limited coverage for codes 93312, 93313, 93314, and 93318:

Covered for:

164.1		Malignant neoplasm of heart
198.89		Secondary malignant neoplasm of other specified sites
212.7		Benign neoplasm of heart
238.8		Neoplasm of uncertain behavior of other specified sites
239.8		Neoplasm of unspecified nature of other specified sites
276.5		Disorders of fluid balance, volume depletion
276.6		Disorders of fluid balance, fluid overload
391.1		Acute rheumatic myocarditis
394.0		Mitral stenosis
394.1		Rheumatic mitral insufficiency
394.2		Mitral stenosis with insufficiency
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
397.0		Diseases of tricuspid
397.1		Rheumatic diseases of pulmonary valve
414.10		Aneurysm of heart (wall)
414.11		Aneurysm of coronary vessels
414.12		Dissection of coronary artery
414.19		Other aneurysm of heart
415.0		Acute cor pulmonale
415.11		Iatrogenic pulmonary embolism and infarction
415.19		Other acute pulmonary heart disease
417.0		Arteriovenous fistula of pulmonary vessels
417.1		Aneurysm of pulmonary artery
421.0		Acute and subacute bacterial endocarditis
421.1		Acute and subacute infective endocarditis in diseases classified
		elsewhere
422.91		Idiopathic myocarditis
422.92		Septic myocarditis
424.0		Mitral valve disorders
424.1		Aortic valve disorders
424.2		Tricuspid valve disorders, specified as nonrheumatic
424.3		Pulmonary valve disorders
424.91		Endocarditis in diseases classified elsewhere
425.1		Hypertrophic obstructive cardiomyopathy
427.31		Atrial fibrillation
429.4		Functional disturbances following cardiac surgery
429.5		Rupture of chordae tendineae
429.6		Rupture of papillary muscle
429.71		Acquired cardiac septal defect
429.81		Other disorders of papillary muscle
440.0		Atherosclerosis of aorta
441.01		Dissecting thoracic aortic aneurysm
441.03		Dissecting thoracoabdominal aortic aneurysm
441.1		Thoracic aneurysm, ruptured
441.2		Thoracic aneurysm without mention of rupture
441.6		Thoracoabdominal aneurysm, ruptured
441.7		Thoracoabdominal aortic aneurysm, without mention of rupture
444.1		Embolism and thrombosis of thoracic aorta
458.9		Hypotension, unspecified
459.2		Compression of vein
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
745.0		Common truncus
745.10		Complete transposition of great vessels
745.11		Doublet outlet right ventricle
745.12		Corrected transposition of great vessels
745.19		Other transposition of great vessels
745.2		Tetralogy of Fallot
745.3		Anomaly of cardiac septal closure, common ventricle
745.4		Ventricular septal defect
745.5		Ostium secundum type atrial septal defect
745.60		Endocardial cushion defect, unspecified type
745.61		Endocardial cushion defect, ostium primum defect
745.69		Other endocardial cushion defects
745.7		Cor biloculare
746.00		Pulmonary valve anomaly, unspecified
746.01		Atresia, congenital
746.02		Pulmonary valve, stenosis, congenital
746.09		Other congenital anomalies of pulmonary valve
746.1		Tricuspid atresia and stenosis, congenital
746.2		Ebstein’s anomaly
746.3		Congenital stenosis of aortic valve
746.4		Congenital insufficiency of aortic valve
746.5		Congenital mitral stenosis
746.6		Congenital mitral insufficiency
746.7		Hypoplastic left heart syndrome
746.81		Subaortic stenosis
746.82		Cor triatriatum
746.83		Infundibular pulmonic stenosis
746.84		Obstructive anomalies of heart, not elsewhere classified
746.85		Coronary artery anomaly
747.0		Patent ductus arteriosus
747.10		Coarctation of aorta (preductal)(postductal)
747.11		Interruption of aortic arch
747.22		Atresia and stenosis of aorta
747.29		Other congenital anomalies of aorta
747.3		Congenital anomalies of pulmonary artery
747.40		Anomaly of great veins, unspecified
747.41		Total anomalous pulmonary venous connection
747.42		Partial anomalous pulmonary venous connection
780.2		Syncope and collapse
785.50		Shock, unspecified
785.51		Cardiogenic shock
785.59		Other shock without mention of trauma
958.4		Traumatic shock
996.01		Mechanical complication due to cardiac pacemaker (electrode)
996.02		Mechanical complications due to heart valve prosthesis
996.61		Infection and inflammatory reaction due to cardiac device, implant, and
		graft
996.71		Other complications due to heart valve prosthesis
996.72		Other complications due other cardiac device, implant, and graft
998.0		Postoperative shock, not elsewhere classified
998.51		Postoperative infection
998.59		Other postoperative infection
999.1		Air embolism as a complication of medical care, not elsewhere
		classified
V15.1		Personal history of surgery to heart and great vessels, presenting hazards
		to health
V42.1		Heart replaced by transplant
V42.6		Lung replaced by transplant
V43.3		Heart valve replaced by other means

Diagnoses that Support Medical Necessity

N/A

ICD-9 Codes that DO NOT Support Medical Necessity

N/A

Diagnoses that DO NOT Support Medical Necessity

N/A

Documentation Requirements

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and available to Medicare upon request.
By using diagnosis code 427.31, the medical records must reflect one of the following ACC/AHA Guidelines for Clinical Application of Echocardiography:
- patients requiring urgent (not emergent) cardioversion for whom extended precardioversion anticoagulation is not desirable.
- patients who have had prior cardioembolic events thought to be related to intra-atrial thrombus.
  patients for whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results.
- patients for whom intra-atrial thrombus has been demonstrated in previous TEE.
  Evaluation of patient for whom a decision concerning cardioversion will be impacted by knowledge of prognostic factors (such as LV function, coexistent mitral valve disease, etc.).
- patients with atrial fibrillation of <48 hours duration and other heart disease.

Utilization Guidelines

Medicare will monitor the utilization of these codes through the Medical Review process.

Sources of Information and Basis for Decision

· TrailBlazer Local Medical Policy

· PM 0-091, CR 2763, Annual Update of ICD-9-CM Codes

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

N/A

End Date of Comment Period

N/A

Start Date of Notice Period

N/A

Revision History

Number	Date	Change
R4	03/09/05	Addition of ICD-9 codes 786.50 and 786.59 for coverage
		of HCPC 93307.
R3	11/01/2004	Addition of ICD-9 codes 434.10-434.11
		434.90-434.91, 435.8-435.9, 444.0, 444.1, 444.21-444.22,
		444.81, 444.89, and 444.9 for HCPCS codes 93307,
		93308, 93320,93321, and 93325
R2	10/01/2004	Removed ICD-9 codes 427.31, 472.32, 674.50-674.54,
		720.0 and 780.2 as they are not appropriate to the policy.
		CPT descriptors converted to short descriptors. Converted
		From LMRP to LCD format.
R1	10/01/2003	Annual ICD-9 update. Changes and additions for HCPCS
		codes 93307, 93308, 93320, 93321and 93325
		are revision of 414.06, of native coronary and
		addition of 414.07. Addition of new ICD-9 codes
		674.50-674.54 to all groups of CPT codes.
		Corrected ICD-9 codes 074.33 to 704.3 and
		093.84 to 098.84.

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.