Myocardial Perfusion Imaging and Cardiac Blood Pool Studies (L31072)
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
L31072 LCD Title Myocardial Perfusion Imaging and Cardiac Blood Pool Studies Contractor's Determination Number CV-017 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 11/15/2010 Original Determination Ending Date Revision Effective Date For services performed on or after 10/01/2011 Revision Ending Date |
CMS National Coverage Policy
Title
XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no
Medicare payment shall be made for items or services that €œare not
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, §1862(a)(7) and 42 Code of Federal Regulations (CFR), §411.15, exclude routine physical examinations.
Title XVIII of the Social Security Act, §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Section 410.32(b) of the Code of Federal Regulations, as adopted in the Medicare physician fee schedule final rule of October 31, 1997, requires that diagnostic tests covered under §1861(s)(3) of the Social Security Act and payable under the physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a "physician"(§1861(r) of the Social Security Act) to be considered reasonable and necessary and, therefore, covered under Medicare.
§4317(b), of the Balanced Budget Act (BBA), specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.
42 Code of Federal Regulations (CFR) §410.32 and §410.33, indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 4
-200.8 - Billing for Nuclear Medicine Procedures
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 12
-20.4.4 - Supplies
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 13
-20 - Payment Conditions for Radiology Services
-50 - Nuclear Medicine
CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 15
-60 - Services and Supplies
-60.1 - Incident To Physician's Professional Services
-80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
-80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests
Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations (CFR), §411.15, exclude routine physical examinations.
Title XVIII of the Social Security Act, §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
Section 410.32(b) of the Code of Federal Regulations, as adopted in the Medicare physician fee schedule final rule of October 31, 1997, requires that diagnostic tests covered under §1861(s)(3) of the Social Security Act and payable under the physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a "physician"(§1861(r) of the Social Security Act) to be considered reasonable and necessary and, therefore, covered under Medicare.
§4317(b), of the Balanced Budget Act (BBA), specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.
42 Code of Federal Regulations (CFR) §410.32 and §410.33, indicates that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 4
-200.8 - Billing for Nuclear Medicine Procedures
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 12
-20.4.4 - Supplies
CMS Publication 100-04, Medicare Claims Processing Manual Chapter 13
-20 - Payment Conditions for Radiology Services
-50 - Nuclear Medicine
CMS Publication 100-02, Medicare Benefit Policy Manual Chapter 15
-60 - Services and Supplies
-60.1 - Incident To Physician's Professional Services
-80 - Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
-80.6 - Requirements for Ordering and Following Orders for Diagnostic Tests
Indications and Limitations of Coverage and/or Medical Necessity
Cardiovascular
nuclear imaging employs noninvasive techniques to assess alterations in
coronary artery flow, as well as ventricular function.
Myocardial perfusion imaging requires intravenous injection of a radioactive agent (radiopharmaceutical/radionuclide).
Often, a second injection is done so that images may be obtained both after stress and at rest.
Diagnostic information obtained includes assessment of blood flow to the myocardium, differentiation of ischemic from infarcted tissue, and identification of reversible and nonreversible defects.
Ventricular function studies may be performed using technetium-based perfusion imaging agents and gated technology and are used to outline the borders of the left ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium.
Patient selection should be based on clinical findings.
Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question.
Patients with a low pretest probability of disease are not usually studied unless a prior exercise stress test demonstrated a presumed false-positive or non-diagnostic result. Selection of the test should be made within the context of other testing modalities to prevent redundancy.
Indications:
The following specific indications may be considered reasonable and necessary and therefore may justify the test:
The patient has an abnormal ECG with a high likelihood of coronary artery disease (CAD) based on multiple risk factors or strongly suggestive symptoms.
The patient takes medication that would make interpretation of a standard exercise test inaccurate.
The patient had an abnormal standard stress test and further evaluation is medically necessary.
The patient has a condition which would likely result in a nondiagnostic or inaccurate standard stress test.
Myocardial perfusion imaging is being done to determine the significance or the extent of myocardial ischemia (or scar), or to assess myocardial viability (e.g., risk stratification following acute myocardial infarction).
The patient has undergone cardiovascular reperfusion: e.g., coronary artery bypass graft, (CABG), percutaneous transluminal coronary angioplasty (PTCA), or thrombolysis, and perfusion imaging is being done to evaluate the effectiveness of the intervention when the patient is symptomatic.
Functional capacity is being assessed when adequate information is not available from the clinical assessment.
The patient has a ventricular wall motion abnormality demonstrated by another imaging modality, and perfusion imaging is needed to further evaluate the abnormality.
The study is used to aid in diagnosis of hypertrophic or dilated cardiomyopathy, or to differentiate ischemic from nonischemic cardiomyopathy.
The study is being done to evaluate a patient receiving chemotherapeutic drugs which are potentially cardio toxic (e.g. doxorubicin).
The study is performed as risk assessment of an intermediate-risk CAD patient prior to high-risk surgery.
A patient with known CAD has a new onset of or a significant change in, symptoms.
To evaluate patients with previously documented silent ischemia where further therapeutic or clinical management decisions are expected.
To evaluate patients in whom silent ischemia is considered highly probable (i.e. a diabetic patient with neuropathic interference with normal sensation of pain).
Post heart transplant for assessment of coronary arteriopathy; or
Evaluation for ventricular dysfunction with post-transplant rejection.
In selected patients, imaging is appropriate in the assessment of patients presenting with chest pain to the Emergency Department;
Unstable coronary syndromes such as angina following acute myocardial infarction typically go directly to coronary angiography. However, a patient with a previous diagnosis of intermediate coronary syndrome, (unstable angina) who is €œmedically stable,€ may be a candidate for nuclear imaging, typically to ascertain whether or not angiography is warranted.
There are currently three main radionuclides used during myocardial perfusion imaging and labeled red blood cells for cardiac blood pool studies.
A9500- Technetium Tc-99m sestamibi, diagnostic, per study dose.
A9502- Technetium Tc 99m tetrofosmin, diagnostic, per study dose.
A9505-TL-201 Thallous chloride, diagnostic, per millicurie, typically an initial dose of 2-4 mCi is given at peak exercise, and imaging is performed immediately, and then 4-6 hours later after redistribution.
A9560-Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries.
Technetium radiopharmaceuticals clear more slowly, allowing imaging up to 4-6 hours post-injection. In a typical one-day protocol, a first dose of 5-8 mCi is given at peak exercise, and a second dose of 15-24 mCi is given at rest, approximately four hours later. In a typical two-day rest/stress protocol, a 24 to 30 mCi dose is given each day.
When medically necessary, cardiovascular stress testing can be performed in conjunction with nuclear medicine procedures. To review related policies, please refer to the LCD titled Cardiovascular Stress Testing.
Limitations:
Cardiovascular Nuclear Imaging would not be considered medically necessary or reasonable:
When incremental information obtained by testing has little or no clinical relevance.
When there is no probability of intervention or change in medical management (e.g., the risk is too high, the patient refuses, or unacceptable comorbidities are present).
When there is repetitive, frequent testing in the absence of changing clinical parameters, especially in individuals with known, stable CAD.
When secondary conditions will potentially decrease both the sensitivity and specificity of testing (e.g., postoperative state, anemia, or poor functional capacity).
When testing is due to first-degree atrioventricular block in an asymptomatic patient with a low-or intermediate-risk profile.
All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified nonphysician (i.e., a nurse practitioner or physician's assistant).
Cardiovascular nuclear tests must be performed under the general supervision of a physician.
Cardiovascular stress testing must be performed under direct physician supervision.
Studies performed for the following indications are not considered reasonable and necessary and therefore will not be paid by Medicare:
Screening for coronary disease, the presence of risk factors alone is not a Medicare-covered indication.
Stimulus to motivate changes in lifestyle (e.g., weight loss or exercise programs do not meet the Medicare medical necessity criteria).
Routine follow-up tests for MI, CABG, or PTCA in the absence of symptoms or clinical indications are not covered (e.g., annual testing in the absence of individualized clinical indications).
Occupational fitness evaluation.
Myocardial perfusion imaging requires intravenous injection of a radioactive agent (radiopharmaceutical/radionuclide).
Often, a second injection is done so that images may be obtained both after stress and at rest.
Diagnostic information obtained includes assessment of blood flow to the myocardium, differentiation of ischemic from infarcted tissue, and identification of reversible and nonreversible defects.
Ventricular function studies may be performed using technetium-based perfusion imaging agents and gated technology and are used to outline the borders of the left ventricular endocardium, or to identify the ventricular blood pool independent of the surrounding myocardium.
Patient selection should be based on clinical findings.
Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question.
Patients with a low pretest probability of disease are not usually studied unless a prior exercise stress test demonstrated a presumed false-positive or non-diagnostic result. Selection of the test should be made within the context of other testing modalities to prevent redundancy.
Indications:
The following specific indications may be considered reasonable and necessary and therefore may justify the test:
The patient has an abnormal ECG with a high likelihood of coronary artery disease (CAD) based on multiple risk factors or strongly suggestive symptoms.
The patient takes medication that would make interpretation of a standard exercise test inaccurate.
The patient had an abnormal standard stress test and further evaluation is medically necessary.
The patient has a condition which would likely result in a nondiagnostic or inaccurate standard stress test.
Myocardial perfusion imaging is being done to determine the significance or the extent of myocardial ischemia (or scar), or to assess myocardial viability (e.g., risk stratification following acute myocardial infarction).
The patient has undergone cardiovascular reperfusion: e.g., coronary artery bypass graft, (CABG), percutaneous transluminal coronary angioplasty (PTCA), or thrombolysis, and perfusion imaging is being done to evaluate the effectiveness of the intervention when the patient is symptomatic.
Functional capacity is being assessed when adequate information is not available from the clinical assessment.
The patient has a ventricular wall motion abnormality demonstrated by another imaging modality, and perfusion imaging is needed to further evaluate the abnormality.
The study is used to aid in diagnosis of hypertrophic or dilated cardiomyopathy, or to differentiate ischemic from nonischemic cardiomyopathy.
The study is being done to evaluate a patient receiving chemotherapeutic drugs which are potentially cardio toxic (e.g. doxorubicin).
The study is performed as risk assessment of an intermediate-risk CAD patient prior to high-risk surgery.
A patient with known CAD has a new onset of or a significant change in, symptoms.
To evaluate patients with previously documented silent ischemia where further therapeutic or clinical management decisions are expected.
To evaluate patients in whom silent ischemia is considered highly probable (i.e. a diabetic patient with neuropathic interference with normal sensation of pain).
Post heart transplant for assessment of coronary arteriopathy; or
Evaluation for ventricular dysfunction with post-transplant rejection.
In selected patients, imaging is appropriate in the assessment of patients presenting with chest pain to the Emergency Department;
Unstable coronary syndromes such as angina following acute myocardial infarction typically go directly to coronary angiography. However, a patient with a previous diagnosis of intermediate coronary syndrome, (unstable angina) who is €œmedically stable,€ may be a candidate for nuclear imaging, typically to ascertain whether or not angiography is warranted.
There are currently three main radionuclides used during myocardial perfusion imaging and labeled red blood cells for cardiac blood pool studies.
A9500- Technetium Tc-99m sestamibi, diagnostic, per study dose.
A9502- Technetium Tc 99m tetrofosmin, diagnostic, per study dose.
A9505-TL-201 Thallous chloride, diagnostic, per millicurie, typically an initial dose of 2-4 mCi is given at peak exercise, and imaging is performed immediately, and then 4-6 hours later after redistribution.
A9560-Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries.
Technetium radiopharmaceuticals clear more slowly, allowing imaging up to 4-6 hours post-injection. In a typical one-day protocol, a first dose of 5-8 mCi is given at peak exercise, and a second dose of 15-24 mCi is given at rest, approximately four hours later. In a typical two-day rest/stress protocol, a 24 to 30 mCi dose is given each day.
When medically necessary, cardiovascular stress testing can be performed in conjunction with nuclear medicine procedures. To review related policies, please refer to the LCD titled Cardiovascular Stress Testing.
Limitations:
Cardiovascular Nuclear Imaging would not be considered medically necessary or reasonable:
When incremental information obtained by testing has little or no clinical relevance.
When there is no probability of intervention or change in medical management (e.g., the risk is too high, the patient refuses, or unacceptable comorbidities are present).
When there is repetitive, frequent testing in the absence of changing clinical parameters, especially in individuals with known, stable CAD.
When secondary conditions will potentially decrease both the sensitivity and specificity of testing (e.g., postoperative state, anemia, or poor functional capacity).
When testing is due to first-degree atrioventricular block in an asymptomatic patient with a low-or intermediate-risk profile.
All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified nonphysician (i.e., a nurse practitioner or physician's assistant).
Cardiovascular nuclear tests must be performed under the general supervision of a physician.
Cardiovascular stress testing must be performed under direct physician supervision.
Studies performed for the following indications are not considered reasonable and necessary and therefore will not be paid by Medicare:
Screening for coronary disease, the presence of risk factors alone is not a Medicare-covered indication.
Stimulus to motivate changes in lifestyle (e.g., weight loss or exercise programs do not meet the Medicare medical necessity criteria).
Routine follow-up tests for MI, CABG, or PTCA in the absence of symptoms or clinical indications are not covered (e.g., annual testing in the absence of individualized clinical indications).
Occupational fitness evaluation.
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.
Revenue Codes:
CPT/HCPCS 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.
| 034X | Nuclear Medicine - General Classification |
| 0482 | Cardiology - Stress Test |
| 0636 | Pharmacy - Drugs Requiring Detailed Coding |
| 0960 | Professional Fees - General Classification |
| 0969 | Professional Fees - Other Professional Fee |
| 0974 | Professional Fees - Radiology Nuclear |
| 0982 | Professional Fees - Outpatient Services |
| 78451 | MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC) |
| 78452 | MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION |
| 78453 | MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); SINGLE STUDY, AT REST OR STRESS (EXERCISE OR PHARMACOLOGIC) |
| 78454 | MYOCARDIAL PERFUSION IMAGING, PLANAR (INCLUDING QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICATION, WHEN PERFORMED); MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE OR PHARMACOLOGIC) AND/OR REDISTRIBUTION AND/OR REST REINJECTION |
| 78466 | MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR QUANTITATIVE |
| 78468 | MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS TECHNIQUE |
| 78469 | MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION |
| 78472 | CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; PLANAR, SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT ADDITIONAL QUANTITATIVE PROCESSING |
| 78473 | CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, AT REST AND STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT ADDITIONAL QUANTIFICATION |
| 78481 | CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION |
| 78483 | CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION |
| 78494 | CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTITATIVE PROCESSING |
| 78496 | CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, AT REST, WITH RIGHT VENTRICULAR EJECTION FRACTION BY FIRST PASS TECHNIQUE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| A9500 | TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE |
| A9502 | TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE |
| A9505 | THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE |
| A9512 | TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE |
| A9539 | TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES |
| A9560 | TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES |
| C9898 | RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY |
ICD-9 Codes that Support Medical Necessity
Diagnosis codes do not apply to A9512 - A9560, C9898.
| 249.00 - 249.91 | SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED - SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED |
| 250.60 - 250.63 | DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 250.90 - 250.93 | DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED |
| 394.0 - 394.9 | MITRAL STENOSIS - OTHER AND UNSPECIFIED MITRAL VALVE DISEASES |
| 395.0 - 395.2 | RHEUMATIC AORTIC STENOSIS - RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY |
| 396.0 - 396.3 | MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY |
| 396.8 | MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES |
| 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 - 410.82 | ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE |
| 410.90 - 410.92 | ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE |
| 411.0 | POSTMYOCARDIAL INFARCTION SYNDROME |
| 411.1 | INTERMEDIATE CORONARY SYNDROME |
| 411.81 | ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION |
| 411.89 | OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER |
| 412 | OLD MYOCARDIAL INFARCTION |
| 413.0 - 413.9 | ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS |
| 414.00 - 414.07 | CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART |
| 414.10 - 414.19 | ANEURYSM OF HEART (WALL) - OTHER ANEURYSM OF HEART |
| 414.2 | CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY |
| 414.3 | CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE |
| 414.4 | CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION |
| 414.8 | OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE |
| 414.9 | CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED |
| 416.9 | CHRONIC PULMONARY HEART DISEASE UNSPECIFIED |
| 424.0 - 424.3 | MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS |
| 425.0 - 425.9 | ENDOMYOCARDIAL FIBROSIS - SECONDARY CARDIOMYOPATHY UNSPECIFIED |
| 426.10 - 426.9 | ATRIOVENTRICULAR BLOCK UNSPECIFIED - CONDUCTION DISORDER UNSPECIFIED |
| 427.0 - 427.89 | PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS |
| 428.0 - 428.9 | CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED |
| 429.0 | MYOCARDITIS UNSPECIFIED |
| 429.1 | MYOCARDIAL DEGENERATION |
| 429.2 | CARDIOVASCULAR DISEASE UNSPECIFIED |
| 429.3 | CARDIOMEGALY |
| 429.4 | FUNCTIONAL DISTURBANCES FOLLOWING CARDIAC SURGERY |
| 429.83 | TAKOTSUBO SYNDROME |
| 429.89 | OTHER ILL-DEFINED HEART DISEASES |
| 433.10 | OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION |
| 433.11 | OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION |
| 440.20 - 440.9 | ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED - GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS |
| 441.00 - 441.9 | DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE - AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE |
| 745.2 - 745.5 | TETRALOGY OF FALLOT - OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT |
| 746.00 - 746.7 | CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - HYPOPLASTIC LEFT HEART SYNDROME |
| 746.81 | SUBAORTIC STENOSIS CONGENITAL |
| 746.85 | CORONARY ARTERY ANOMALY CONGENITAL |
| 780.2 | SYNCOPE AND COLLAPSE |
| 785.1 | PALPITATIONS |
| 786.02 | ORTHOPNEA |
| 786.05 | SHORTNESS OF BREATH |
| 786.09 | RESPIRATORY ABNORMALITY OTHER |
| 786.50 | UNSPECIFIED CHEST PAIN |
| 786.51 | PRECORDIAL PAIN |
| 786.59 | OTHER CHEST PAIN |
| 794.30 | UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM |
| 794.31 | NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) |
| 995.20 | UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE |
| 996.03 | MECHANICAL COMPLICATION DUE TO CORONARY BYPASS GRAFT |
| 996.1 | MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
| 996.71 | OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS |
| 996.72 | OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT |
| 996.83 | COMPLICATIONS OF TRANSPLANTED HEART |
| V15.1 | PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH |
| V42.1 | HEART REPLACED BY TRANSPLANT |
| V42.2 | HEART VALVE REPLACED BY TRANSPLANT |
| V43.3 | HEART VALVE REPLACED BY OTHER MEANS |
| V45.81 | POSTSURGICAL AORTOCORONARY BYPASS STATUS |
| V45.82 | PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS |
| V58.11 | ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY |
| V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
| V67.51 | FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED |
| V72.81 | PRE-OPERATIVE CARDIOVASCULAR EXAMINATION |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
The condition and
treatment is expected to be documented in the medical record and be
available upon request.
Medical records must substantiate the medical necessity of the services, including a clinical diagnosis, the specific reason for the study, the reason for use of pharmacologic stress, and must include a formal interpretation and report.
Medical records must contain a copy of the referral order, and the reason for Add-on procedure codes. Code 78496 will be denied if not used in conjunction with code 78472.
Documentation in the patient's medical record must show that physician supervision of testing was in compliance with applicable regulations of the Centers for Medicare & Medicaid Services.
When billing for the purchase of radiopharmaceutical(s), the name, purchase records, dosage administered, and unit price per dose must be on file and available to the contractor upon request.
Appendices
Medical records must substantiate the medical necessity of the services, including a clinical diagnosis, the specific reason for the study, the reason for use of pharmacologic stress, and must include a formal interpretation and report.
Medical records must contain a copy of the referral order, and the reason for Add-on procedure codes. Code 78496 will be denied if not used in conjunction with code 78472.
Documentation in the patient's medical record must show that physician supervision of testing was in compliance with applicable regulations of the Centers for Medicare & Medicaid Services.
When billing for the purchase of radiopharmaceutical(s), the name, purchase records, dosage administered, and unit price per dose must be on file and available to the contractor upon request.
Rest/stress
protocols are reimbursed as one test whether done on the same day or two
separate days.
Sources of Information and Basis for Decision
Hendel RC, Berman
DS, Di Carli MF, Heidenreich PA, Henkin RE, Pellikka PA, Pohost GM,
Williams KA. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use
criteria for cardiac radionuclide imaging: a report of the American
College of Cardiology Foundation Appropriate Use Criteria Task Force,
the American Society of Nuclear Cardiology, the American College of
Radiology, the American Heart Association, the American Society of
Echocardiography, the Society of Cardiovascular Computed Tomography, the
Society for Cardiovascular Magnetic Resonance, and the Society of
Nuclear Medicine. J Am Coll Cardiol 2009;53:2201-29.
Baggish AL, Boucher CA, Radiopharmaceutical Agents for Myocardial Perfusion Imaging Circulation 2008;118;1668-1674
Gibbons RJ, Askew JW Hodge D Miller TD Temporal trends in compliance with appropriateness criteria for stress single photon emission computed tomography sestamibi studies in an academic medical center Am Heart J 2010 Mar159(3):484-9.
Other Contractors LCDs
Advisory Committee Meeting Notes
Baggish AL, Boucher CA, Radiopharmaceutical Agents for Myocardial Perfusion Imaging Circulation 2008;118;1668-1674
Gibbons RJ, Askew JW Hodge D Miller TD Temporal trends in compliance with appropriateness criteria for stress single photon emission computed tomography sestamibi studies in an academic medical center Am Heart J 2010 Mar159(3):484-9.
Other Contractors LCDs
Meeting Date:
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
J5 MAC
IA, KS, MO, NE, 06/24/2010
Open Meeting 04/22/2010
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction
Start Date of Comment Period
Wisconsin: 06/18/2010
Illinois: 05/19/2010
Michigan: 05/12/2010
Minnesota: 05/06/2010
J5 MAC
IA, KS, MO, NE, 06/24/2010
Open Meeting 04/22/2010
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction
06/24/2010
End Date of Comment Period
08/08/2010
Start Date of Notice Period
10/01/2010
Revision History Number
X
Revision History Explanation
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 - Revenue code 0343 was added to the code range 0340 - 0349
8/1/2010 - Revenue code 0344 was added to the code range 0340 - 0349
8/1/2010 - The description for Revenue code 0340 was changed
8/1/2010 - The description for Revenue code 0341 was changed
8/1/2010 - The description for Revenue code 0342 was changed
8/1/2010 - The description for Revenue code 0349 was changed
8/1/2010 - The description for Revenue code 0482 was changed
8/1/2010 - The description for Revenue code 0636 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - The description for Revenue code 0974 was changed
8/1/2010 - The description for Revenue code 0982 was changed
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 those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
10/21/2010 corrected statement under Documentation Requirements; Code 78496 will be denied if not used in conjunction with code 78472.
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:
78451 descriptor was changed in Group 1
78452 descriptor was changed in Group 1
78453 descriptor was changed in Group 1
78454 descriptor was changed in Group 1
78472 descriptor was changed in Group 1
78473 descriptor was changed in Group 1
78481 descriptor was changed in Group 1
78483 descriptor was changed in Group 1
78494 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 ICD-9 annual code updates added code 414.4, codes 425.11 and 425.18 added to range effective 10/01/2011.
Reason for Change
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 - Revenue code 0343 was added to the code range 0340 - 0349
8/1/2010 - Revenue code 0344 was added to the code range 0340 - 0349
8/1/2010 - The description for Revenue code 0340 was changed
8/1/2010 - The description for Revenue code 0341 was changed
8/1/2010 - The description for Revenue code 0342 was changed
8/1/2010 - The description for Revenue code 0349 was changed
8/1/2010 - The description for Revenue code 0482 was changed
8/1/2010 - The description for Revenue code 0636 was changed
8/1/2010 - The description for Revenue code 0960 was changed
8/1/2010 - The description for Revenue code 0969 was changed
8/1/2010 - The description for Revenue code 0974 was changed
8/1/2010 - The description for Revenue code 0982 was changed
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 those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
10/21/2010 corrected statement under Documentation Requirements; Code 78496 will be denied if not used in conjunction with code 78472.
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:
78451 descriptor was changed in Group 1
78452 descriptor was changed in Group 1
78453 descriptor was changed in Group 1
78454 descriptor was changed in Group 1
78472 descriptor was changed in Group 1
78473 descriptor was changed in Group 1
78481 descriptor was changed in Group 1
78483 descriptor was changed in Group 1
78494 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 ICD-9 annual code updates added code 414.4, codes 425.11 and 425.18 added to range effective 10/01/2011.
This LCD has no Related Documents.
LCD Attachments
Coding and Billing Guidelines 10/01/2010 (PDF - 62 KB )
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Page Last Updated: Thursday, 20-Oct-2011 15:45:16 CDT
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