Transesophageal Echocardiography (Including Intraoperative TEE) (L28574)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation		 Contractor Number
00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402		 Contractor Type
Carrier - FI - MAC

LCD Information

Document Information
LCD ID Number
L28574

LCD Title
Transesophageal Echocardiography (Including Intraoperative TEE)

Contractor's Determination Number
CV-007

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction


Oversight Region

Original Determination Effective Date
For services performed on or after 03/18/2009

Original Determination Ending Date


Revision Effective Date
For services performed on or after 10/01/2011

Revision Ending Date


CMS National Coverage Policy
Pub.100-4, Ch. 12, §30.4
Indications and Limitations of Coverage and/or Medical Necessity
I Transesophageal Echocardiography (TEE)
Cardiac ultrasound provides structural, functional and hemodynamic information. It can also provide anatomic information pertaining to the proximal great vessels. An ultrasound generator can noninvasively be applied to the anterior thorax to examine the heart. This is transthoracic echocardiography (TTE). The ultrasound generator can be positioned in the esophagus to obtain additional cardiovascular information. This is transesophageal echocardiography (TEE).

The equipment, first introduced in 1976, is a two-dimensional Doppler color flow imaging system to which an endoscopic ultrasound transducer is attached and passed into the esophagus allowing two-dimensional images to be obtained from the posterior aspect of the heart.

TEE is not usually medically necessary when a technically adequate normal TTE has been performed. If TTE is technically inadequate, or demonstrates pathology but does not provide adequate data for definitive therapeutic decision, TEE is appropriately considered. The information TEE is expected to provide should significantly augment that obtained by TTE and contribute to clinically relevant management decision (alter therapy).

Significant esophageal pathology (tumor, stenosis, varices, diverticula, dysphagia, and recent esophageal surgery, GI bleeding) is considered as relatively contraindicating TEE. The anticipated incremental information obtained clearly should exceed any potential risk.

This policy defines clinical pathophysiologic states for which this carrier will provide coverage for TEE examinations. Covered conditions reflect those for which there is authoritative literature support as to clinical utility.

Coverage for TEE is considered appropriate when a TTE has not established the diagnosis, or in a patient where TTE will most likely result in insufficient information. Insufficient information can result from extreme obesity, severe COPD, patients with prosthetic material, and certain chest deformities. Inadequate or incomplete visualization of the left atrium and left atrial appendage may also necessitate a TEE.

Inadequate visualization of the atrial septum for making the diagnosis of patent foramen ovale is another example of an appropriate indication of TEE.

A. Native Valvular Heart Disease and Valvular Prosthetics: Native valvular heart disease in the absence of proven or suspected endocarditis is appropriately assessed by TTE. It is seldom medically necessary to complement TTE with TEE. TTE provides noninvasive assessment of native value functional anatomy and ventricular adaptation and function. When TTE is technically inadequate, TEE may provide comparable data. Serial assessment by relatively invasive TEE is not as ideal as serial assessment by noninvasive TTE.

In most patients with valvular prostheses TTE provides diagnostic function information and noninvasive serial follow-up. In some patients acoustical shadowing can decrease the quality of data acquisition. When prosthetic dysfunction is suspect, therapeutic decisions are pivotal and data inconclusive, TEE is appropriately considered.

B. Endocarditis: TTE provides diagnostic information pertaining to valvular pathology, the infective process and ventricular function, affords noninvasive serial assessment and is generally better able to define the consequences of the infective valvular process on ventricular function. When TTE has provided diagnostic information, the supplemental information provided by TEE should generally have therapeutic relevance. When the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology involvement of a prosthetic valve) and TTE does not document endocarditis, TEE may define small vegetative masses and more completely delineate local complications (e.g. ring abscesses, aneurysm, and fistulae).

C. Suspected Cardiac Thrombi and Emboli: Historical estimates place the incidence of a cardiac source of emboli at up to 20% of acute neurological events. In general, TTE can reliably diagnose or exclude a ventricular locus of potentially embolic material. In patients with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias - especially atrial fibrillation, cardiomyopathies, other causes of ventricular dysfunction) the incremental information provided by TEE should be of therapeutic relevance before the patient is subjected to TEE. In younger stroke patients (generally < 45 years old) with a normal TTE and neurological workup, TEE is appropriately considered. A key decisional factor should be whether TEE findings may substantively alter therapy and clinical outcome. TEE is particularly appropriate for detection of left atrial thrombus, left atrial spontaneous contrast, atrial septal aneurysm, and patent foramen ovale.

D. Aortic Pathology: TEE has become an established rapid and reliable tool for the diagnosis and definition of aortic dissection and aneurysm. Sensitivity and specificity in the range of 97% are consistently reported. In suspected aortic dissection, the application of bedside biplane or multiplane TEE is frequently considered the diagnostic study "of choice". TEE is also appropriate to follow-up after surgical repair of aortic dissection when complication is suspected.

Aortic ulceration, atherosclerotic plaque and mural thrombotic material are identified by TEE. If embolic episodes are repetitive, and focused aortic surgical intervention is contemplated, use of TEE to search for and characterize remediable aortic lesions may be appropriate.

E. Congenital Heart Disease: In children and smaller adults TTE provides accurate anatomic definition of congenital heart diseases. In larger and postoperative patients with fibrosis, echo opaque patches and prostheses, inadequate penetration and acoustical shadowing can result in incomplete TTE data. The more precise definition of atrial, outflow tract and proximal pulmonary vascular anomalies by TEE can be critical to management strategies. When TTE is technically inadequate or anatomic definition incomplete, TEE is appropriately considered.

F. Critically Ill ICU Patients: There is a role for echocardiography in the management of the critically ill patient. When TTE fails to provide adequate visualization (COPD, ventilator patient) TEE may provide diagnostic information and help guide therapy. 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. TEE may be effectively utilized in early postoperative cases where the diagnostic quality of a TTE is impaired.

G. Cardiac Tumor and Mass Assessment: TTE and TEE have comparable sensitivity in the assessment of right heart masses. TEE provides more detail of left atrial masses and may provide therapeutic direction (cystic vs. solid, attachment, and infiltration). When cardiac mass lesions are suspect, TEE can be an integral part of the diagnostic workup and management strategy.

H. Left Ventricular Function: In general, TTE provides accurate and serial noninvasive assessment of global and regional left ventricular function. When TTE is technically inadequate and clinical data insufficient for management decision, TEE can provide comparable information. In these circumstances TEE can direct therapy by distinquishing among extensive infarction with pump failure, mechanical complications of infarction or hypovolemia. TTE assessment of left ventricular function is considered preferable to TEE in all other circumstances.

I. Cardioversion of Patients with Atrial Fibrillation: Echocardiography has a distinct role in evaluation of patients to identify those most likely to have successful cardioversion and maintain sinus rhythm after the procedure. The following ACC guidelines list indications for TEE before cardioversion:

a. Patients requiring urgent (not emergent) cardioversion for whom extended pre-cardioversion anticoagulation is not desirable.
b. Patients who have had prior cardioembolie events thought to be related to intra-atrial thrombus.
c. Patients for whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results.
d. Patients for who intra-atrial thrombus has been demonstrated in previous TEE.

J. Interventional and Surgical TEE: See section below entitled Diagnostic Intraoperative Transesophageal Echocardiography

K. Arrhythmias requiring electrophysiological ablative procedures: echocardiography is an appropriate pre-procedure evaluation tool for these patients.

L. Ventricular Tachycardia: echocardiography may be appropriately utilized in these patients with suspected arrhythmogenic right ventricular dysplasia.

M. I.V. Contrast Agents:
Intravenous injection of approved contrast agents is useful in the enhancement of 2-dimentional echocardiographic images and Doppler spectral recordings in patients with sub-optimal studies. The agents facilitate images in regional wall motion abnormalities, ventricular opacification and enhance delineation of endocardial borders. The difficult to image patient may be defined as those with obesity, lung disease or other co-morbidities that would render an echocardiographic study without contrast sub-optimal. Existing publication have defined sub-optimal 2-dimentional and Doppler studies as those in which 2 of 6 segments in a standard apical echocardiographic view are not visualized on the baseline study, and an inability to obtain recordings of the complete maximum velocity from Doppler spectral profiles.

II Diagnostic Intraoperative Transesophageal Echocardiography
Diagnostic Intraoperative TEE, is indicated when the surgical procedure is expected to alter the anatomy or function of the cardiac or thoracic structures:

1. If the evaluation of cardiac function and/or thoracic structures is necessary for the safe conduct of anesthesia or surgery.
2. If the surgical technique will be affected by the intra-operative TEE findings, thus assisting in surgical management decisions.
3. If thoracic structures and/or cardiac function were not adequately evaluated pre-operatively AND the information is necessary for the safe conduct of anesthesia and surgery.

CPT Code 93318: Routine application of intra-operative TEE, even in-patients undergoing cardiopulmonary bypass and valvular surgery, cannot be supported. CPT code 93318 (TEE for monitoring purpose) is not a medically necessary service intraoperatively.

Intraoperative TEE should only be performed by physicians who are qualified by training and experience, and who are credentialed by their hospital/medical center to perform and interpret TEE.

Intraoperative TEE includes a complete written interpretation/report by the performing physician and must be available if requested. Archiving of the video tapes/video disk, of the examination is highly desirable.


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.

012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
021x Skilled Nursing - Inpatient (Including Medicare Part A)
071x Clinic - Rural Health
073x Clinic - Freestanding
085x Critical Access Hospital

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.

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.

For dates of service on or after July 1, 2006, the following revenue codes should be used when billing for RHC or FQHC services, other than those services subject to the Medicare outpatient mental health treatment limitation or for the FQHC supplement payment: 0521, 0522, 0524, 0525, 0527 and 0528. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100.)

Revenue codes 096X, 097X and 098X are to be used only by Critical Access Hospitals (CAHs) choosing the optional payment method (also called Option 2 or Method 2) and only for services performed by physicians or practitioners who have reassigned their billing rights. When a CAH has selected the optional payment method, physicians or other practitioners providing professional services at the CAH may elect to bill their carrier or assign their billing rights to the CAH. When professional services are reassigned to the CAH, the CAH must bill the FI using revenue codes 096X, 097X or 098X.
0480 Cardiology - General Classification
0483 Cardiology - Echocardiology

CPT/HCPCS Codes

93312ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT
93313ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY
93314ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY
93315TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT
93316TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY
93317TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY
93318ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS
93320DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE
93321DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING)
93325DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY)
A9700SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, PER STUDY
Q9955INJECTION, PERFLEXANE LIPID MICROSPHERES, PER ML
Q9956INJECTION, OCTAFLUOROPROPANE MICROSPHERES, PER ML
Q9957INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML

For Hospital Claims paid under OPPS

C8925TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT
C8926TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT
C8927TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS

ICD-9 Codes that Support Medical Necessity

Note: ICD-9 codes must be coded to the highest level of specificity.

For use with CPT codes 93312, 93313, 93314, 93315, 93316 and 93317

038.0 - 038.9STREPTOCOCCAL SEPTICEMIA - UNSPECIFIED SEPTICEMIA
164.1MALIGNANT NEOPLASM OF HEART
198.89SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
212.7BENIGN NEOPLASM OF HEART
238.8NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES
239.89NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES
276.50 - 276.69VOLUME DEPLETION, UNSPECIFIED - OTHER FLUID OVERLOAD
391.0 - 391.2ACUTE RHEUMATIC PERICARDITIS - ACUTE RHEUMATIC MYOCARDITIS
392.0RHEUMATIC CHOREA WITH HEART INVOLVEMENT
394.0 - 394.2MITRAL STENOSIS - MITRAL STENOSIS WITH INSUFFICIENCY
395.0 - 395.9RHEUMATIC AORTIC STENOSIS - OTHER AND UNSPECIFIED RHEUMATIC AORTIC DISEASES
396.0 - 396.8MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES
397.0 - 397.9DISEASES OF TRICUSPID VALVE - RHEUMATIC DISEASES OF ENDOCARDIUM VALVE UNSPECIFIED
398.0RHEUMATIC MYOCARDITIS
398.90RHEUMATIC HEART DISEASE UNSPECIFIED
410.00 - 410.92ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
414.10 - 414.19ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART
414.2CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY
414.8OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
415.0 - 415.19ACUTE COR PULMONALE - OTHER PULMONARY EMBOLISM AND INFARCTION
416.0 - 416.8PRIMARY PULMONARY HYPERTENSION - OTHER CHRONIC PULMONARY HEART DISEASES
417.0ARTERIOVENOUS FISTULA OF PULMONARY VESSELS
417.1ANEURYSM OF PULMONARY ARTERY
421.0 - 421.1ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS - ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
422.0ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
422.91 - 422.92IDIOPATHIC MYOCARDITIS - SEPTIC MYOCARDITIS
423.3CARDIAC TAMPONADE
423.9UNSPECIFIED DISEASE OF PERICARDIUM
424.0 - 424.91MITRAL VALVE DISORDERS - ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE
425.0 - 425.9ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED
427.1PAROXYSMAL VENTRICULAR TACHYCARDIA
427.31 - 427.32ATRIAL FIBRILLATION - ATRIAL FLUTTER
427.81SINOATRIAL NODE DYSFUNCTION
427.89OTHER SPECIFIED CARDIAC DYSRHYTHMIAS
428.0 - 428.9CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
429.0 - 429.9MYOCARDITIS UNSPECIFIED - HEART DISEASE UNSPECIFIED
434.00 - 434.91CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION
435.0 - 435.9BASILAR ARTERY SYNDROME - UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA
436ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
440.0ATHEROSCLEROSIS OF AORTA
441.01 - 441.7DISSECTION OF AORTA THORACIC - THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE
444.1EMBOLISM AND THROMBOSIS OF THORACIC AORTA
458.8 - 458.9OTHER SPECIFIED HYPOTENSION - HYPOTENSION UNSPECIFIED
459.2COMPRESSION OF VEIN
745.0 - 745.19COMMON TRUNCUS - OTHER TRANSPOSITION OF GREAT VESSELS
745.2 - 745.7TETRALOGY OF FALLOT - COR BILOCULARE
746.00 - 746.85CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - CORONARY ARTERY ANOMALY CONGENITAL
747.0 - 747.42PATENT DUCTUS ARTERIOSUS - PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION
780.60 - 780.65FEVER, UNSPECIFIED - HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE
785.50 - 785.59SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA
901.0 - 901.9INJURY TO THORACIC AORTA - INJURY TO UNSPECIFIED BLOOD VESSEL OF THORAX
958.4TRAUMATIC SHOCK
995.90 - 995.92SYSTEMIC INFLAMMATORY RESPONSE SYNDROME UNSPECIFIED - SEVERE SEPSIS
995.93SYSTEMIC INFLAMMATORY RESPONSE SYNDROME DUE TO NONINFECTIOUS PROCESS WITHOUT ACUTE ORGAN DYSFUNCTION
995.94SYSTEMIC INFLAMMATORY RESPONSE SYNDROME DUE TO NONINFECTIOUS PROCESS WITH ACUTE ORGAN DYSFUNCTION
996.00 - 996.02MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT - MECHANICAL COMPLICATION DUE TO HEART VALVE PROSTHESIS
996.61 - 996.72INFECTION AND INFLAMMATORY REACTION DUE TO CARDIAC DEVICE IMPLANT AND GRAFT - OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT
997.1CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED
998.00 - 998.59POSTOPERATIVE SHOCK, UNSPECIFIED - OTHER POSTOPERATIVE INFECTION
999.1AIR EMBOLISM AS A COMPLICATION OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED
V15.1PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH
V42.1HEART REPLACED BY TRANSPLANT
V42.2HEART VALVE REPLACED BY TRANSPLANT
V42.6LUNG REPLACED BY TRANSPLANT
V43.21HEART REPLACED BY HEART ASSIST DEVICE
V43.3HEART VALVE REPLACED BY OTHER MEANS
V59.8DONORS OF OTHER SPECIFIED ORGAN OR TISSUE
Q9955, Q9956, Q9957, A9700(Supply of injectable contrast material for use in echocardiography as described in CPT code section).
794.39OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM
796.4OTHER ABNORMAL CLINICAL FINDINGS

Diagnoses that Support Medical Necessity
Diagnoses listed above.
ICD-9 Codes that DO NOT Support Medical Necessity
Any ICD-9 code not listed above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
Diagnoses not listed above.
 

General Information

Documentations Requirements
Documentation supporting the medical necessity of this item, such as ICD-9 codes, must be submitted with each claim Claims submitted without such evidence will be denied as being not medically necessary.

The patient's medical record should be legible, contain the relevant history, physical findings conforming to the criteria stated in the "Indications and Limitations of Coverage" section of this policy and must be made available to the Carrier on request.

Training Requirements: It is not this Contractor's intention to credential providers for TEE. However, Medicare does expect a satisfactory level of competence from providers who submit claims for services rendered. It is well known that substandard studies often lead to repetition of studies and overutilization of services. It is expected that based on their experience and/or training, that such images will be submitted for interpretation. Providers of the technical component must provide high quality images that allow proper interpretation. If the quality of the technical component is a poor quality and/or does not lead to an appropriate professional interpretation, it is not a medically necessary service and thus not payable. Similarly, providers of the professional component must provide proper interpretations, based on their experience and/or training.
Appendices
Utilization Guidelines
Outlined in Indications and Limitations section.
Sources of Information and Basis for Decision
1. ACC/AHA Task Force Report, "ACC/AHA Guidelines for the Clinical Application of Echocardiography", Circulation Vol. 95, No 6, March 1997: 1686-1744

2. Harrison's Principles of Internal Medicine, 13th ed. (Eds.Isselbacher kJ, Braunwald E. Wilson JD, Martin JB, Fauci AS, Kasper DL) McGraw-Hill, New York (1994)

3. Heart Disease A Textbook of Cardiovascular Medicine, 4th ed. (Ed. Braunwald E) WB Saunders, Philadelphia, PA (1992)

4. AHA Medical/Scientific Statement (Feinberg WM, chair) Guidelines for the management of transient ischemic attacks. From the ad hoc committee on guidelines for the management of transient ischemic attacks of the stroke council of the American heart association. Stroke 1994; 25:1320-1335

5. Ansari A., Transesophageal two-dimensional echocardiography: current perspectives. Prog Cardiovascular Dis., 1993; 35(5): 349-397

6. Besson G, Bogousslavsky J, Hommel M, et al. Patent foramen ovale in young stroke patients with mitral valve prolapse. Acta Neurol Scand 1994; 89:23-26

7. Blanchard, Daniel, et. al., "Transesophageal Echocardiography of the Aorta", JAMA, August 17, 1994-Vol. 272, No. 7

8. Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neurol 1986; 43:71-84

9. Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Eng. J Med. 1993; 328(1): 35-43

10. Daniel WG, Mugge A. Transeophageal echocardiography. N Eng. J Med. 1995; 332(19): 1268-1279

11. Daniel WG. Transcatheter closure of patient foramen ovale. Therapeutic overkill or elegant management for selected patients at risk? Circulation 1992; 86(6): 2013-2015 (editorial)

12. DeBelder MA, Lovat LB, Tourikis L, Leech G, Camm AJ. Limitations of transoesophageal echocardiography in patients with focal cerebral ischaemic events. Br Heart J 1992; 67:297-303

13. DeBelder MA, Tourikis L, Leech G, Camm J. Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol 1992; 69:1316-1320

14. Demopoulos LA, Tunick PA, Bernstein NE, et al. Protruding atheromas of the aortic arch in symptomatic patients with carotid artery disease. Am Heart J 1995; 129:40-44

15. DeRook FA, Comess KA, Albers GW, Popp RL. Transesophageal echocardiography in the evaluation of stroke. Ann Intern Med. 1992; 117:922-932

16. Dhandheria, Bijoy, et. Al., "Transesophageal Echocardiography; Concise Review for Primary - Care Physicians", Mayo Clinic Proc. 1994, 69:856-863

17. Hanna JP, Sun JP, Furlan AJ, et al. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke. 1994; 25:782-786

18. Homma S, DiTullioi MR, Sacco RL, et al. Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke 1994; 25:582-586

19. Jones EF, Calafiore P, Donnan GA, Tonkin AM. Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly. Am J Cardiol 1994; 74:596-599

20. Khoury AF, Afridi I, Quinones MA, Zoghbi WA. Transesophageal echocardiography in critically ill patients: feasibility, safety, and impact on management. Am Heart J 1994; 127:1363-1371'

21. Kronzon I, Tunick PA. Transesophageal echocardiography as a tool in the evaluation of patients with embolic disorders. Prog Cardiovasc Dis. 1993; 36(1): 39-60

22. Lindower PD, Gutterman DD. Detection of cardioembolic sources with echocardiography. Comprehensive Therapy 1994; 20(3): 174-180

23. Louie EK, Konstadt SN, Rao TLK, Scanlon PJ. Transesohageal echocardiographic diagnosis of right to left shunting across the foramen ovale I adults without prior stroke. J Am Coll Cardiol 1993; 21:1231-1237

24. Lucas C, Goullard L, Marchau Jr. M, et al. Higher prevalence of atrial septal aneurysms in patient with ischemic stroke of unknown cause. Acta Neurol Scand 1994; 89:210-213

25. Mitusch R, Stierle U, Tepe C, et al. Systemic embolism in aortic arch atheromatosis. Euro Heart J 1994; 15:1373-1380

26. Mugge A, Daniel WG, Haverich A, Lichtlen PR. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches. Circulation 1991; 83:70-78

27. Pearlman AS. Detecting prosthetic valve dysfunction. ACCEL 1995; 27(10): tape B, side 3 (interview with Holmes, Jr. DR)

28. Pearlman AS. Transesophageal echocardiography - sound diagnostic technique or two-edged sword? N Eng. J Med. 1991; 324(12): 841-843 (editorial)

29. Pearson AC, Nagelhout D, Castello R, et al. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol 1991; 18:1223-1229

30. Petty GW, Orencia AJ, Khandheria BK, Whisnant JP. A population-based study of stroke in the setting of mitral valve prolapse; risk factors and infarct subtype classification. Mayo Clin Proc 1994; 69:632-634

31. Sansoy V, Abbott RD, Jayaweera AR, Kaul S. Low yield of transthoracic echocardiography for cardiac source of embolism. Am J Cardiol 1995; 75:166-169

32. Stratton JR, Lighty, Jr. GW, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivity, specificity, and causes of uncertainty. Circulation 1982; 66:156-166

33. Wiet SP, Pearce WH, McCarthy WJ, et al. Utility of transesophageal echocardiography in the diagnosis of disease of the thoracic aorta. J Vasc Surg 1994; 29:613-620

34. MCM 15360. Transmittal 1670, June 2000. (Pub. 100-4, 12, §30.4)

Sources of Information and Basis for Decision for Intraoperative Transesophageal Echocardiography

1. American Society of Anesthesiologists (ASA); Practice Guidelines for Perioperative Transesophageal Echocardiography

2. American Society of Echocardiography (ASE), Society of Cardiovascular Anesthesiologists (SCA) (1999, June). Guidelines for Intraoperative Transesophageal Echocardiography. Author


3. ASA Statement on Transesophageal Echocardiography. (2001, March). Author

4. ASA Taskforce on Perioperative Transesophageal Echocardiography (1996).Practice guidelines for perioperative transesophageal echocardiography. Anesthesiology 84: 986 - 1006. Author

5. Kentucky LMRP CV-1-0006

6. WPS LCD CV-007

7. WPS LCD CV-034
Advisory Committee Meeting Notes
Meeting Date:
Wisconsin 09/26/2008
Illinois 09/17/2008
Michigan 09/24/2008
Minnesota 09/11/2008
Iowa 10/16/2008
Kansas 10/16/2008
Missouri 10/17/2008
Nebraska 10/16/2008

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee, which includes representatives from cardiology, internal medicine, anesthesiology, surgery and all relevant medical societies.
Start Date of Comment Period
10/18/2008
End Date of Comment Period
12/03/2008
Start Date of Notice Period
02/01/2009
Revision History Number
4
Revision History Explanation
11/01/2010; Added new for 2011 ICD-9-CM codes 276.61 and 276.69 to ICD-9-CM coding range 276.50-276.69, effective 10/01/2010 (three).

10/01/2009, 2010 ICD-9 coding update, revenue code 0483 incorrectly listed (two)

Correctly removed contract number 05392 effective 8/1/2009, as it is being combined with contractor number 05302 (WPS Part B MAC Missouri - Entire State.) JS 07/30/09



08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update.

09/08/2009 Sent to approved due to ICD-9 2008-2009 Annual Update.



3/7/2010 - The description for Bill Type Code 73 was changed

04/19/2010-In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor  Palmetto.

8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 21 was changed
8/1/2010 - The description for Bill Type Code 71 was changed
8/1/2010 - The description for Bill Type Code 73 was changed
8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0480 was changed
8/1/2010 - The description for Revenue code 0483 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of
Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for
these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor
Trailblazers (04901).

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:
93320 descriptor was changed in Group 1
93321 descriptor was changed in Group 1

02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

10/01/2011: Added new for 2012 ICD-9-CM code 415.13 to coding range 415.0-415.19; ICD-9-CM codes 425.11 and 425.18 to coding range 425.0-425.9; ICD-9-CM codes 747.31, 747.32 and 747.39 to coding range 747.0-747.42; expanded coding range 998.0-998.59 to 998.00-998.59 to included truncated ICD-9-CM codes 998.00, 998.01, 998.02 and 998.09. For use with CPT codes 93312, 93313, 93314, 93315, 93316 and 93317. Effective 10/01/2011 (four).
Reason for Change
Related Documents
This LCD has no Related Documents.

LCD Attachments

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Page Last Updated: Thursday, 20-Oct-2011 15:27:04 CDT