Percutaneous Coronary Interventions (PCI) (L28478)

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
L28478

LCD Title
Percutaneous Coronary Interventions (PCI)

Contractor's Determination Number
CV-037

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 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 02/16/2009

Original Determination Ending Date


Revision Effective Date
For services performed on or after 05/01/2011

Revision Ending Date


CMS National Coverage Policy
CMS Manual System, Medicare National Coverage Determinations Manual (Pub. 100-3, Chapter 1, § 20.7 describes coverage of Percutaneous Transluminal Angioplasty (PTA).


Title XVIII of Social Security Act, Section 1862(a)(1)(A) excludes Medicare coverage for "items or services that are 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, section 1833(e) prohibits Medicare Payment for any claim which lacks the necessary information to process the claim.


Title XVIII of the Social Security Act, section 1862(a)(7) excludes routine physical examinations.


42CFR 410.32 Diagnostic tests may only be ordered by the treating physician (or other treating practitioners acting within the scope of their licenses and Medicare requirements) who will use the results in the management of the beneficiary's specific medical problem and diagnostic tests payable under the Physicians Fee Schedule must be furnished under the appropriate level of supervision by the physician.


42CFR 411.15(a)(1) excludes coverage for routine physical check-ups and examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptom, complaint or injury.


CMS Manual System, Medical Benefit Policy Manual, Pub. 100-2, Chapter 6, § 70.4 for outpatient observation services.


CMS Manual System, Medicare Claims Processing Manual, Pub. 100-4, Chapter 23, § 10.1-10.1.7; Chapter 12, §30; 40-49; 70.
Indications and Limitations of Coverage and/or Medical Necessity
Percutaneous transluminal coronary angioplasty was first introduced in 1977 as a nonsurgical method for coronary arterial revascularization. Coronary balloon angioplasty substantively altered the management of individuals with symptomatic arteriosclerotic heart disease. Balloon angioplasty rapidly expanded from single to multiple vessels and simple to complex anatomic substrates. Percutaneous coronary interventions (PCI) now encompass balloon dilatation, a variety of atherectomy devices and stents approved for coronary placement. Complementing medical therapy and aortocoronary bypass, PCI have emerged as a third therapeutic option for the management of patients with angina and evolving myocardial infarction.


Definitions:


Coronary Balloon Angioplasty (92982, 92984): The technique of advancing a balloon tipped catheter into an area of coronary narrowing, inflating the balloon and the removing the catheter.


Percutaneous Atherectomy (92995, 92996): The technique of advancing a catheter with a rotating shaver or other device on the end of the catheter to remove the atheromatous plaque from a blood vessel.


Coronary Stents (92980, 92981): Balloon expandable or self expanding devices implanted into the coronary arteries for the purpose of providing mechanical support to the vessel wall.


Intracoronary Thrombolysis (92975): is the infusion of thrombolytic agents via selective coronary artery catheterization to the site of the acute coronary thrombosis


In this policy the contractor relates existing procedural descriptors, defines indications for coverage and documentation requirements. Claim submission instructions and situations that will result in denied services will be contained in a companion document (See "Notes"). These definitions and instructions are provided to reiterate existing Medicare policy and philosophic intent. They are intended to provide a flexible framework to meet the challenges of evolving technology and advances in physician experience and expertise.


PCI are appropriately considered in those patients who manifest either acute or chronic signs and symptoms of myocardial ischemia, who have not responded to medical therapy, for whom the alternative is aortocoronary bypass, who have objective evidence of myocardial ischemia and have lesions amenable to percutaneous intervention. Medicare recognizes only three coronary arteries when considering first or additional vessel interventions, generally allows one PCI per vessel and has designated modifiers for each; the left anterior descending (LD), the left circumflex (LC) and the right coronary (RC) arteries.


  1. Diagnostic Cardiac Catheterization:



    1. The full diagnostic cardiac catheterization is done prior to the PCI to identify the vessels and define the clinical pathology for the PCI procedure, this should be reported in the catheterization report as part of the patients record. The cardiac catheterization may be performed before the PCI or during the same session. Reporting the cardiac catheterization for mere placement of the PCI catheter is considered not medically necessary.



    2. If the diagnostic catheterization is done within 30 days of the PCI, it is usually not necessary to repeat the catheterization unless there is a documented change in the patient's condition or outside films accompanying the patient on transfer are of insufficient quality to make the decision. Additional focused studies done at the time of the procedure will be included and/or reimbursed as defined by CCI.




  2. Intracoronary Thrombolysis:


    3. The patient's medical records must support the medical necessity of this procedure when performed with other stent placement.


  3. Frequency of PCI:


    4. Rarely is it medically necessary to perform PCI on multiple vessels at separate operative sessions. Nearly all multi-vessel PCI can be safely performed at the same session. Pre-existing medical conditions or other contributing medical factors may warrant the performance of a "staged" PCI procedure.



    1. Emergency complication such as restenosis, reocclusion, etc. on the same or different vessels would support the medical necessity to return to the operative suite/cardiac catheterization lab on the same date of services.



    2. Coverage for repeat PCI after the initial treatment within the same hospitalization or in subsequent encounters must show evidence of recurrent ischemia and anatomic changes to support the medical need for PCI.



    3. When excessive repeat procedures or staged procedures are detected a case review may be performed to determine coverage for repeat PCI.




  4. Other Coverage Issues:



    1. The PCI procedures must be performed in a hospital setting.



    2. The procedure must be performed by an interventional cardiologist with experience in interventional procedures who has undergone the appropriate training courses and in accordance with the hospital protocols



    3. Determination of the PCI method and device used is at the discretion of the physician.




  5. When participating in clinical trials for PCI procedures and devices, see PHYS-067 (NCP) for Part B.



  6. Based on the coronary stent CPT procedure code description, multiple stent placement in the same vessel will be reimbursed the same as a single stent placement.





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.

011x Hospital Inpatient (Including Medicare Part A)
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
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.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
0360 Operating Room Services - General Classification
0402 Other Imaging Services - Ultrasound
0480 Cardiology - General Classification
0481 Cardiology - Cardiac Cath Lab
0960 Professional Fees - General Classification
0982 Professional Fees - Outpatient Services

CPT/HCPCS Codes

HCPCS codes G0290 and G0291 are only billable to the intermediary or Part A MAC.

92973PERCUTANEOUS TRANSLUMINAL CORONARY THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92974TRANSCATHETER PLACEMENT OF RADIATION DELIVERY DEVICE FOR SUBSEQUENT CORONARY INTRAVASCULAR BRACHYTHERAPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92975THROMBOLYSIS, CORONARY; BY INTRACORONARY INFUSION, INCLUDING SELECTIVE CORONARY ANGIOGRAPHY
92978INTRAVASCULAR ULTRASOUND (CORONARY VESSEL OR GRAFT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92979INTRAVASCULAR ULTRASOUND (CORONARY VESSEL OR GRAFT) DURING DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92980TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL
92981TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92982PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; SINGLE VESSEL
92984PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
92995PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY; SINGLE VESSEL
92996PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
G0290TRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL
G0291TRANSCATHETER PLACEMENT OF A DRUG ELUTING INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; EACH ADDITIONAL VESSEL

ICD-9 Codes that Support Medical Necessity

Note: ICD-9 codes must be coded to the highest level of specificity
410.00 - 410.02ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE
410.10 - 410.12ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE
410.20 - 410.22ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE
410.30 - 410.32ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE
410.40 - 410.42ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE
410.50 - 410.52ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE
410.60 - 410.62TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE
410.70 - 410.72SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE
410.80 - 410.82ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE
410.90 - 410.92ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
411.0 - 412POSTMYOCARDIAL INFARCTION SYNDROME - OLD MYOCARDIAL INFARCTION
413.0 - 413.9ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS
414.00 - 414.06CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART
414.11ANEURYSM OF CORONARY VESSELS
414.12DISSECTION OF CORONARY ARTERY
414.8OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE
414.9CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED
429.2CARDIOVASCULAR DISEASE UNSPECIFIED
785.51CARDIOGENIC SHOCK
996.00MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT
996.02MECHANICAL COMPLICATION DUE TO HEART VALVE PROSTHESIS
996.03MECHANICAL COMPLICATION DUE TO CORONARY BYPASS GRAFT
996.72OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT
996.83COMPLICATIONS OF TRANSPLANTED HEART
997.1CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED

Diagnoses that Support Medical Necessity
NA
ICD-9 Codes that DO NOT Support Medical Necessity
NA

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

Diagnoses that DO NOT Support Medical Necessity
NA

General Information

Documentations Requirements
Physician Services and diagnostic tests must be submitted with an ICD-9 code to support medical necessity and must be coded to the greatest level of accuracy and highest level of digit completeness. This means the precise ICD-9 code that most fully explains the narrative description of the diagnosis contained in the medical record or test interpretation and report including the 4 th and 5 th digit sub classification for that diagnosis category. The ICD-9 code based on the results of the diagnostic test should be reported as the primary diagnosis. If the diagnostic test results are normal or inconclusive the ICD-9 code representing the sign, symptom, illness or injury prompting the ordering of the test should be reported as the primary diagnosis. In the absence of signs, symptoms, illness or injury a screening ICD-9 should be reported, and payment will be denied.


The patient's medical records should be legible, contain the relevant medical history and physical findings conforming to the criteria stated in the "Indication and Limitations of Coverage and/or Medical Necessity" section of this policy. Records must be made available to the Contractor on request.


Hospital or outpatient (or freestanding cardiac catheterization units, if approved) should clearly document the reason for the procedure, what was done and the results in a procedure report and also in progress notes and the discharge summary.


All right heart catheterizations should have a formal procedural and interpretation report. Placement of multiple stents in the same vessel should only be performed when medically necessary and must be accompanied by the appropriate documentation to establish that the intervention was reasonable and necessary. This documentation must include photographic reproduction of the pre-interventional arteriographic data.
Appendices
Utilization Guidelines

  1. Single Percutaneous Coronary Interventions (PCI):


    2. When a single interventional modality is utilized in more than one of these three vessels, the first vessel is to be identified using the respective "single vessel" code (92980, 92982, 92995). Each additional major coronary vessel instrumented is to be identified using the "each additional vessel" code (92981, 99284, 92996). Branch vessels are considered an integral part of these three parent, major, named coronary arteries. Interventions in branch vessels are considered a part of and included with intervention in the named parent vessel. Anatomic variants (large ramus or marginal branches, unbalanced circulatory patterns, etc.) should be referenced as precisely as possible to a corresponding named vessel. (See Reasons for Denial) Special consideration will be provided when multiple bypass conduits have a common named vessel distal anastomosis and when transluminal interventions are performed on both native vessels and bypass conduits (See #12). In the presence of bypass conduits, for purposes of these definitions, the left main coronary artery is considered a part of the major left system vesselreceiving antegrade flow.

  2. Multiple Percutaneous Coronary Interventions (PCI):

    3. Medicare also recognizes a hierarchical schema in technical complexity when multiple types of coronary intervention are employed in a single session on multiple vessels. Generally, stent placement supersedes atherectomy, which supersedes angioplasty. The Medicare Correct Coding Initiative (CCI) defines this hierarchical ordering. When multiple transluminal interventions are combined during a single session on multiple vessels, coding should reflect this ranking schema; the most complex intervention is to be identified by using that intervention's "single vessel" code (92980 or 92995 or 92982) and additional interventions using the appropriate "each additional vessel" code (92981, 92996, 92984). (See Reasons for Denial) This same format is applicable when multiple interventions are performed in bypass conduits and/or native vessels.



The following situation will result in the denial of initially billed PCI services or in some cases as a result of a postpayment review.


  1. Use of an interventional device, or technologic modification, that has not received FDA approval, unless being used in a documented clinical trial, will be denied as non-covered.



  2. Single vessel codes and/or each additional vessel codes applied to arteries other than the named major coronary arteries as recognized by Medicare will be denied as not medically necessary.



  3. Multiple same "single vessel codes" reported for the same or different named major coronary arteries/bypass conduit recognized by Medicare in the same session will be denied as not medically necessary.



  4. Multiple different "single vessel codes" reported for the same or different named major coronary arteries/bypass conduit recognized by Medicare in the same session will be denied as not medically necessary.



  5. Multiple same or different "each additional vessel codes" reported for the same named major coronary arteries/bypass conduit recognized by Medicare in the same session will be denied as not medically necessary.



  6. Cardiac catheterization used merely for placement of the PCI catheters will be denied as not medically necessary.


  7. Intracoronary thrombolysis reported with stent placement will deny in accordance with CCI.



  8. Claims submitted without "an ICD-9 code" to support medical necessity will be denied as not medically necessary.



  9. When staged procedures are found to be performed on a routine, customary and habitual basis for all patients the services will be denied as not medically necessary.



  10. When PTCT and/or IVUS are found to be routinely, customarily and habitually reported with PCI, the services will be denied as not medically necessary.



  11. Physicians' Services submitted without "an ICD-9 code" or not coded to the greatest degree of accuracy and digit level completeness will be denied as unprocessable.

Sources of Information and Basis for Decision
Existing LCDs from Other Contractors


American Medical Association, 2008 CPT, Physician's Current Procedural Coding Expert, 2008


International Classification of Disease, 9th Revision Clinical Modification (ICD-9 CM), Sixth Edition, Hospital Edition Ingenix, 2008 Expert


Smith, ET Al., ACC/AHA Guidelines for Percutaneous Coronary Intervention (Revision of the 1993 PTCA Guidelines) JACC Vol. 37, No 8 June 2001


Smith, ET Al., ACC/AHA Guidelines for Percutaneous Coronary Intervention (2005 Update) JACC Vol. 47, January 3, 2006


Smith ET Al., ACC/AHA Guidelines for Percutaneous Coronary Intervention 2007 (Focused Update) JACC Vol. 51, January 15, 2008
Advisory Committee Meeting Notes
Start Date of Comment Period
10/17/2008
End Date of Comment Period
12/03/2008
Start Date of Notice Period
01/01/2009
Revision History Number
X
Revision History Explanation
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

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.

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).

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:
92974 descriptor was changed in Group 1
92975 descriptor was changed in Group 1
92978 descriptor was changed in Group 1
92979 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).

05/01/2011, Updated the policy by adding bill type and revenue codes and removing states from the Intermediary jurisdiction.
Reason for Change
Last Reviewed On Date
04/21/2011
Related Documents
This LCD has no Related Documents.

LCD Attachments

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Page Last Updated: Tuesday, 07-Jun-2011 13:28:25 CDT