CMS Limitations Guide - Cardiovascular Services

[Pages:29]CMS Limitations Guide - Cardiovascular Services

Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes.

This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: .

CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient's test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses.

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: medicalnecessity.

If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 9357493.

CMS Limitations Guide ? Cardiovascular Services

(L34637) Transthoracic Echocardiography (TTE)

2D Echo Doppler (93306) 3D Echo (93306) Echo (93306) Echo Dobutamine (93351) Stress Echo (93351)

CPT Code 93303 93304 93306 93307 93308 93320 93321 93325 93350 93351

93352 C8921 C8922 C8923 C8924 C8928

C8929

C8930

Description

Transthoracic echocardiography for congenital cardiac anomalies; complete

Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study

Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography (2D Echo Doppler) (3D Echo) (Echo) Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, follow-up or limited study Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete Doppler 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) Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography) Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional (Echo Dobutamine) (Stress Echo) Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure) Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, followup or limited study Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during

CMS Limitations Guide ? Cardiovascular Services

rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision

Group 2 Paragraph: HCPCS Contrast Agent Codes

Group 2 Codes:

Code

Description

A9700

Supply of injectable contrast material for use in echocardiography, per study

Q9955

Injection, perflexane lipid microspheres, per ml

Q9956

Injection, octafluoropropane microspheres, per ml

Q9957

Injection, perflutren lipid microspheres, per ml

ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program:

Group 1 Paragraph: Note: ICD-10 codes must be coded to the highest level of specificity.

For use with CPT codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351

Group 1 Codes:

Code

Description

A02.1

Salmonella sepsis

A18.84

Tuberculosis of heart

A22.7

Anthrax sepsis

A26.7

Erysipelothrix sepsis

A32.7

Listerial sepsis

A40.0

Sepsis due to streptococcus, group A

A40.1

Sepsis due to streptococcus, group B

A40.3

Sepsis due to Streptococcus pneumoniae

A40.8

Other streptococcal sepsis

A41.01

Sepsis due to Methicillin susceptible Staphylococcus aureus

A41.02

Sepsis due to Methicillin resistant Staphylococcus aureus

A41.1

Sepsis due to other specified staphylococcus

A41.3

Sepsis due to Hemophilus influenzae

A41.4

Sepsis due to anaerobes

A41.51

Sepsis due to Escherichia coli [E. coli]

A41.52

Sepsis due to Pseudomonas

A41.53

Sepsis due to Serratia

A41.59

Other Gram-negative sepsis

CMS Limitations Guide ? Cardiovascular Services

A41.81 A41.89 A42.7 A52.01 A52.02 A52.03 A52.04 A52.05 A52.06 A52.09 A54.83 A54.86 A69.21 A69.22 A69.23 A69.29 B20 B33.21 B33.22 B33.23 B37.6 B37.7 B44.81 B57.0 B57.2 B58.81 C38.0 C45.2 C79.89 C96.5 C96.6 D15.1 D48.7 D57.00

Sepsis due to Enterococcus Other specified sepsis Actinomycotic sepsis Syphilitic aneurysm of aorta Syphilitic aortitis Syphilitic endocarditis Syphilitic cerebral arteritis Other cerebrovascular syphilis Other syphilitic heart involvement Other cardiovascular syphilis Gonococcal heart infection Gonococcal sepsis Meningitis due to Lyme disease Other neurologic disorders in Lyme disease Arthritis due to Lyme disease Other conditions associated with Lyme disease Human immunodeficiency virus [HIV] disease Viral endocarditis Viral myocarditis Viral pericarditis Candidal endocarditis Candidal sepsis Allergic bronchopulmonary aspergillosis Acute Chagas' disease with heart involvement Chagas' disease (chronic) with heart involvement Toxoplasma myocarditis Malignant neoplasm of heart Mesothelioma of pericardium Secondary malignant neoplasm of other specified sites Multifocal and unisystemic Langerhans-cell histiocytosis Unifocal Langerhans-cell histiocytosis Benign neoplasm of heart Neoplasm of uncertain behavior of other specified sites Hb-SS disease with crisis, unspecified

CMS Limitations Guide ? Cardiovascular Services

D57.01 D57.02 D57.1 D81.3 D81.5 D81.810 D84.1 D86.0 D86.1 D86.2 D86.3 D86.81 D86.82 D86.83 D86.84 D86.85 D86.86 D86.87 D86.89 E51.11 E51.12 E71.310 E71.311 E71.312 E71.313 E71.314 E71.318 E71.32 E71.39 E71.41 E71.42 E71.43 E71.440 E71.448

Hb-SS disease with acute chest syndrome Hb-SS disease with splenic sequestration Sickle-cell disease without crisis Adenosine deaminase [ADA] deficiency Purine nucleoside phosphorylase [PNP] deficiency Biotinidase deficiency Defects in the complement system Sarcoidosis of lung Sarcoidosis of lymph nodes Sarcoidosis of lung with sarcoidosis of lymph nodes Sarcoidosis of skin Sarcoid meningitis Multiple cranial nerve palsies in sarcoidosis Sarcoid iridocyclitis Sarcoid pyelonephritis Sarcoid myocarditis Sarcoid arthropathy Sarcoid myositis Sarcoidosis of other sites Dry beriberi Wet beriberi Long chain/very long chain acyl CoA dehydrogenase deficiency Medium chain acyl CoA dehydrogenase deficiency Short chain acyl CoA dehydrogenase deficiency Glutaric aciduria type II Muscle carnitine palmitoyltransferase deficiency Other disorders of fatty-acid oxidation Disorders of ketone metabolism Other disorders of fatty-acid metabolism Primary carnitine deficiency Carnitine deficiency due to inborn errors of metabolism Iatrogenic carnitine deficiency Ruvalcaba-Myhre-Smith syndrome Other secondary carnitine deficiency

CMS Limitations Guide ? Cardiovascular Services

E71.510 E71.511 E71.518 E71.520 E71.521 E71.522 E71.528 E71.53 E71.540 E71.541 E71.542 E71.548 E74.01 E74.02 E74.03 E74.04 E74.09 E76.01 E76.02 E76.03 E76.1 E76.210 E76.211 E76.22 E76.29 E76.8 E79.1 E79.2 E79.8 E80.0 E80.1 E80.21 E80.29 E80.3

Zellweger syndrome Neonatal adrenoleukodystrophy Other disorders of peroxisome biogenesis Childhood cerebral X-linked adrenoleukodystrophy Adolescent X-linked adrenoleukodystrophy Adrenomyeloneuropathy Other X-linked adrenoleukodystrophy Other group 2 peroxisomal disorders Rhizomelic chondrodysplasia punctata Zellweger-like syndrome Other group 3 peroxisomal disorders Other peroxisomal disorders von Gierke disease Pompe disease Cori disease McArdle disease Other glycogen storage disease Hurler's syndrome Hurler-Scheie syndrome Scheie's syndrome Mucopolysaccharidosis, type II Morquio A mucopolysaccharidoses Morquio B mucopolysaccharidoses Sanfilippo mucopolysaccharidoses Other mucopolysaccharidoses Other disorders of glucosaminoglycan metabolism Lesch-Nyhan syndrome Myoadenylate deaminase deficiency Other disorders of purine and pyrimidine metabolism Hereditary erythropoietic porphyria Porphyria cutanea tarda Acute intermittent (hepatic) porphyria Other porphyria Defects of catalase and peroxidase

CMS Limitations Guide ? Cardiovascular Services

E80.4 E80.5 E80.6 E83.10 E83.110 E83.111 E83.118 E83.19 E84.0 E84.11 E84.19 E84.8 E85.0 E85.1 E85.3 E85.4 E85.8 E86.0 E86.1 E87.71 E87.79 E88.3 E88.41 E88.42 E88.49 E88.81 E88.89 G11.1 G45.0 G45.1 G45.2 G45.3 G45.8 G46.0

Gilbert syndrome Crigler-Najjar syndrome Other disorders of bilirubin metabolism Disorder of iron metabolism, unspecified Hereditary hemochromatosis Hemochromatosis due to repeated red blood cell transfusions Other hemochromatosis Other disorders of iron metabolism Cystic fibrosis with pulmonary manifestations Meconium ileus in cystic fibrosis Cystic fibrosis with other intestinal manifestations Cystic fibrosis with other manifestations Non-neuropathic heredofamilial amyloidosis Neuropathic heredofamilial amyloidosis Secondary systemic amyloidosis Organ-limited amyloidosis Other amyloidosis Dehydration Hypovolemia Transfusion associated circulatory overload Other fluid overload Tumor lysis syndrome MELAS syndrome MERRF syndrome Other mitochondrial metabolism disorders Metabolic syndrome Other specified metabolic disorders Early-onset cerebellar ataxia Vertebro-basilar artery syndrome Carotid artery syndrome (hemispheric) Multiple and bilateral precerebral artery syndromes Amaurosis fugax Other transient cerebral ischemic attacks and related syndromes Middle cerebral artery syndrome

CMS Limitations Guide ? Cardiovascular Services

G46.1 G46.2 G71.0 G71.11 G71.12 G71.13 G71.14 G71.19 G71.2 G72.0 G72.1 G72.2 H34.01 H34.02 H34.03 H34.11 H34.12 H34.13 H34.211 H34.212 H34.213 H34.231 H34.232 H34.233 H49.811 H49.812 H49.813 I00 I01.0 I01.1 I01.2 I01.8 I02.0 I02.9

Anterior cerebral artery syndrome Posterior cerebral artery syndrome Muscular dystrophy Myotonic muscular dystrophy Myotonia congenita Myotonic chondrodystrophy Drug induced myotonia Other specified myotonic disorders Congenital myopathies Drug-induced myopathy Alcoholic myopathy Myopathy due to other toxic agents Transient retinal artery occlusion, right eye Transient retinal artery occlusion, left eye Transient retinal artery occlusion, bilateral Central retinal artery occlusion, right eye Central retinal artery occlusion, left eye Central retinal artery occlusion, bilateral Partial retinal artery occlusion, right eye Partial retinal artery occlusion, left eye Partial retinal artery occlusion, bilateral Retinal artery branch occlusion, right eye Retinal artery branch occlusion, left eye Retinal artery branch occlusion, bilateral Kearns-Sayre syndrome, right eye Kearns-Sayre syndrome, left eye Kearns-Sayre syndrome, bilateral Rheumatic fever without heart involvement Acute rheumatic pericarditis Acute rheumatic endocarditis Acute rheumatic myocarditis Other acute rheumatic heart disease Rheumatic chorea with heart involvement Rheumatic chorea without heart involvement

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