75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium
75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3d image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)
75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3d image postprocessing, assessment of lv cardiac function, rv structure and function and evaluation of venous structures, if performed)
75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3d image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) (CTA Coronary Arteries)
CT Coronary Angiography (CCTA)
As an alternative to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.
Instead of myocardial perfusion imaging in the evaluation of coronary artery disease in those patients who have moderate pre-test probability of disease based on clinical risk factors and abnormal diagnostic studies, not symptoms alone.
To evaluate the cause of symptoms in patients with known coronary artery disease.
Assessment of suspected congenital anomalies of coronary circulation or great vessels.
Assessment of coronary or pulmonary venous anatomy for the procedures described below:
CTA of the coronary veins is indicated when imaging of the coronary venous anatomy is necessary for biventricular pacemaker lead insertion.
CTA of the pulmonary veins is indicated when imaging of the pulmonary vasculature is necessary for pulmonary vein catheter ablation procedures for atrial fibrillation.
Procedure Codes: 75574
Current Indications New Indications Cardiac evaluation for patient with suspected coronary artery disease:
Evaluate patient with suspected coronary artery disease, who is in the low or intermediate risk category for coronary artery disease when stress echocardiography and/or ETT (exercise treadmill testing) is equivocal.
Nonacute symptoms possibly representing an ischemic equivalent: Low pretest probability of CAD; ECG interpretable and able to exercise
Nonacute symptoms possibly representing an ischemic equivalent: Intermediate pretest probability of CAD; ECG interpretable AND able to exercise
Nonacute symptoms possibly representing an ischemic equivalent: Low pretest probability of CAD; ECG interpretable or unable to exercise
- The Multi-Detector Computed Tomography (MDCT) (Cardiovascular Computed Tomography (CCT)) may be employed for the following:
- Emergency evaluation of acute chest pain syndrome for coronary etiology, including emergency evaluation, pulmonary embolism, aortic dissection and coronary artery disease.
- Cardiac evaluation of a patient with chest pain syndrome (e.g., anginal equivalent, angina) who is not a candidate for cardiac catheterization.
- Management of a symptomatic patient with known coronary artery disease (e.g., post-stent, post-CABG) when the results of the MDCT may guide the decision for repeat invasive intervention.
- Assessment of suspected congenital anomalies of coronary circulation or great vessels.
- Assessment of coronary veins prior to biventricular pacing lead placement.
- Coverage of CT coronary angiography is limited to CT devices that process thin (up to 1 mm) slice, 0.5 to 0.75 mm reconstruction, and multiple simultaneous images.
- The selection of the test should be made within the context of other testing modalities so that the resulting information facilitates the management decision, not merely adds a new layer of testing. Patient selection should be made with a high pretest probability of disease and must not be used for screening. This includes:
- Patients with irregular heart rhythm.
- Patients who have difficult breath hold, which of course will be much better with the 64-slice CT.
- Patients with extreme morbid obesity will be a limitation.
- Patients with serious intravenous iodinated contrast allergies.
- Patients with renal insufficiency for fear of contrast-induced nephropathy.
- Heavily calcified coronary arteries would be a limiting factor for exact determination of diameter stenosis.
- Patients with acute coronary syndrome with chest pain and S-ST segment changes should go directly for invasive coronary angiogram.
- Radiation exposure should be considered as one of the limiting factors.
- Electron Beam CT (EBCT) is not covered for use in coronary artery examination.
- The patient’s treating physician or qualified non-physician practitioner must order the study.
- Studies must be conducted under the direct supervision of a cardiologist and/or radiologist. IV beta blockers may be administered by a qualified non-physician practitioner as long as the direct supervision requirements are met.
- All studies must be done by staff trained and accredited to perform computed tomography.
The supervising and interpreting physician must have appropriate additional training in CT coronary angiography and cardiac CT imaging, equivalent to the guidelines set forth by the ACC (for cardiologists) and ACR (for radiologists), as found in the ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance and the ACR Clinical Statement on Non-Invasive Cardiac Imaging.
The CPT Category III Cardiac Computed Tomography Angiography (CCTA) codes include thorough review and reporting on all of the CT source images acquired. Per the ACR guidelines, non-cardiac structures imaged at the time of cardiac imaging must be reviewed and reported for pathology in addition to the cardiac structures. Medicare expects that when the CPT Category III CCTA codes are reported, all of the work described by the codes will have been performed. Although a physician may elect to have a separate physician interpret a portion of the images (e.g., non-cardiac structure images interpreted by a radiologist and cardiac structures interpreted by a cardiologist) only one professional component per study may be reported to Medicare regardless of the number of physicians contributing to the overall interpretation.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Since the majority of the clinical research utilized a 64-slice CT scanner it is the recommended equipment. However, the intent of this LCD is not to monitor equipment utilization.
The procedure must be performed under the direct supervision of and interpreted by a cardiologist or radiologist who meets the competency guidelines outlined by the published guidelines, ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance, or American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging.
Using 71275 or 76497
Screening tests are defined as those tests done in the absence of signs, symptoms, or presence of disease. The use of these procedures (75572, 75573, 75574 for coronary CT angiography) in patients without signs, symptoms or presence of disease is considered to be screening by this Contractor.
Group 1 Paragraph: N/A
Group 1 Codes:
75571 COMPUTED TOMOGRAPHY, HEART, WITHOUT CONTRAST MATERIAL, WITH QUANTITATIVE EVALUATION OF CORONARY CALCIUM
75572 COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)
75573 COMPUTED TOMOGRAPHY, HEART, WITH CONTRAST MATERIAL, FOR EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY IN THE SETTING OF CONGENITAL HEART DISEASE (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF LV CARDIAC FUNCTION, RV STRUCTURE
AND FUNCTION AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)
75574 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEART, CORONARY ARTERIES AND BYPASS GRAFTS (WHEN PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING (INCLUDING EVALUATION OF CARDIAC STRUCTURE AND MORPHOLOGY, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRUCTURES, IF PERFORMED)
Coverage Indications, Limitations, and/or Medical Necessity
The multi-detector helical computed tomography (MDCT) technology requires thin (up to 1 mm) slices, 0.5 to 0.75 mm reconstructions, multiple simultaneous images (e.g. 16, 32, 64 or more slices), and cardiac gating (often requiring beta blockers for ideal heart rate). There is significant post-processing, depending on the number of slices per second for image generation. For coronary artery imaging, the resulting images show a high correlation with stenotic lesions noted on diagnostic cardiac catheterization but more importantly, with atheromas on intracoronary ultrasound.
Current available body of evidence demonstrates that CCTA can reliably rule out the presence of significant coronary artery disease (CAD) in patients with a low to intermediate probability of having CAD and can reliably achieve a high degree of diagnostic accuracy and technical performance necessary to replace conventional angiography.
CCTA used as an alternative to invasive angiography and stress testing. For patients with anginal symptoms, patients with unclear stress tests results, patients in whom the stress test result contradicts the clinical assessment, to determine the patency of coronary artery bypass grafts, as an alternative when cardiac catheterization is impossible or carries a high risk, to rule out stenosis before non-coronary cardiac surgery such as valve replacement or resection of tumors, and clarifying unclear finding after invasive angiography.
CCTA used to assess patient suspected of having a congenital coronary anomaly of great vessels, cardiac chambers and valves. It is often used after an anomaly has been identified following a different test such as prior invasive coronary angiogram. CCTA is used to decide if surgery is indicated and for surgical planning.
CCTA used to evaluate acute chest pain in the emergency department (ED). The rationale is to quickly triage patients in order to rule out coronary artery disease as a possible cause of symptoms. Many will present with a normal electrocardiogram and myocardial enzymes.
CCTA used to assess coronary or pulmonary venous anatomy. Coronary mapping is primarily for pre-surgical planning such as pacemaker lead placement in the lateral coronary vein to resynchronize cardiac contraction in patients with heart failure, or guiding biventricular pacemaker placement. Pulmonary vein anatomy can vary from patient to patient. Pulmonary vein mapping is primarily for catheter ablation which can isolate electrical activity from the pulmonary veins and allow for the elimination of recurrent atrial fibrillation, or help eliminate procedural complications.
CCTA used to assess etiology with new onset heart failure for evaluation of coronary arteries.
The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
The test will be considered not medically necessary if the anticipated results are not expected to provide new, additional information to that already previously obtained from other tests (such as stress myocardial perfusion images or cardiac ultrasound). New or additional information should facilitate the management decision, not merely add a new layer of testing.
The test will be considered not medically necessary if pretest evaluation indicates that the patient would require invasive cardiac angiography for further diagnosis or for therapeutic intervention.
The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation if there were pre-test knowledge of sufficiently extensive calcification of the suspect coronary segment that would diminish the interpretive value. (e.g., angina decubitus, unstable angina, Prinzmetal angina, etc.)
Coverage is limited to devices that process thin, high resolution slices (1mm or less). The multi-detector scanners must have at least 64 slices per rotation capability.
The administration of beta blockers and the monitoring of the patient during MDCT/CCTA by a physician experienced in the use of cardiovascular drugs is included as part of the test and is not a separately payable service.
All studies must be ordered by the physician/qualified non-physician practitioner treating the
patient and who will use the results of the test in the management of the patient.
The test must be performed under the direct supervision of a physician, similar to the stress myocardial perfusion imaging.
This LCD does not address electron beam tomography (EBT) technology or Ultrafast CT for coronary artery examination. There is no extension of coverage of EBT based on this policy.
Quantitative calcium scoring is not a covered service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening service. When performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring.
Atrial fibrillation or atrial flutter alone is not an indication; atrial fibrillation or atrial flutter with planned ablation therapy is allowed.
Coding and Billing Guidelines
1. *As stated in the 2010 CPT, providers are instructed not to bill 75571 with 75572-75574.
2. ICD-9-CM code listings may cover a range and include truncated codes. It is the provider’s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed.
3. It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid.
4. *Medicare will only pay one professional service for interpretation even if multiple interpretations are obtained by multiple specialties.
The American Medical Association (AMA) instructs physicians not to bill 75571 with 75572-75574.
Computed Tomography to Detect Coronary Artery Calcification
Coronary artery calcium (CAC) has been recognized to be associated with CAD on the basis of anatomic studies for decades. The development of fast CT scanners has allowed the measurement of CAC in clinical practice. CAC has been evaluated in several clinical settings. The most widely studied indication is for the use of CAC in the prediction of future risk for CAD in patients with subclinical disease, with the goal of instituting appropriate risk-reducing therapy (eg, statin treatment; lifestyle modifications) to improve outcomes. In addition, CAC has been evaluated in patients with symptoms potentially consistent with CAD, but in whom a diagnosis is unclear.
Several types of fast computed tomography (CT) imaging, including electron beam computed tomography (EBCT) and spiral CT, allow the quantification of calcium in coronary arteries. Coronary artery calcium (CAC) is associated with coronary artery disease (CAD). The use of CAC scores has been studied in the prediction of future risk of CAD and in the diagnosis of CAD in symptomatic patients. EBCT (also known as ultrafast CT) and spiral CT (or helical CT) may be used as an alternative to conventional CT scanning due to their faster throughput, their speed of image acquisition gives them unique value for imaging of the moving heart. The rapid image acquisition time virtually eliminates motion artifact related to cardiac contraction, permitting visualization of the calcium in the epicardial coronary arteries. EBCT software permits quantification of calcium area and density, which are translated into calcium scores. Calcium scores have been investigated as a technique for detecting coronary artery calcification, both as a technique to diagnostic technique in symptomatic patients to determine the necessity of coronary angiography, or, in asymptomatic patients, as a screening technique for coronary artery disease.
EBCT and multi-detector computed tomography (MDCT) were initially the primary fast CT methods for measurement of coronary artery calcification. A fast CT study for coronary artery calcium measurement generally takes 10 to 15 minutes and requires only a few seconds of scanning time. More recently, CT angiography has been used to assess coronary calcium. Because of the basic similarity between EBCT and CT angiography in measuring coronary calcium, it is expected that CT angiography provides similar information on coronary calcium as does EBCT.
CT scan‒derived coronary calcium measures have been used to evaluate coronary atherosclerosis. Coronary calcium is present in coronary atherosclerosis, but the atherosclerosis detected may or may not be causing ischemia or symptoms. Coronary calcium measures may be correlated with the presence of critical coronary stenoses or serve as a measure of the patient’s proclivity toward atherosclerosis and future coronary disease. Thus, it could serve as a variable to be used in a risk assessment calculation for the purposes of determining appropriate preventive treatment in asymptomatic patients. Alternatively, in other clinical scenarios, it might help determine whether there is atherosclerotic etiology or component to the presenting clinical problem in symptomatic patients, thus helping to direct further workup for the clinical problem. In this second scenario, a calcium score of zero usually indicates that the patient’s clinical problem is unlikely to be due to atherosclerosis and that other etiologies should be more strongly considered. In neither case does the test actually determine a specific diagnosis. Most clinical studies have examined the use of coronary calcium for its potential use in estimating the risk of future coronary heart disease (CHD) events.
Coronary calcium levels can be expressed in many ways. The most common method is the Agatston score, which is a weighted summed total of calcified coronary artery area observed on CT. This value can be expressed as an absolute number, commonly ranging from 0 to 400. These values can be translated into age and sex-specific percentile values. Different imaging methods and protocols will produce different values based on the specific algorithm used to create the score, but the correlation between any 2 methods appears to be high, and scores from 1 method can be translated into scores from a different method.
when Computed Tomography to Detect Coronary Artery Calcification is not covered
Computed tomography to detect coronary artery calcification is considered investigational for all services, including:
• detection of coronary artery calcification as a screening examination for asymptomatic patients
• as a diagnostic study in symptomatic patients
• assessment of coronary artery bypass graft patency
• measurement of cardiac perfusion.
There is extensive evidence on the predictive value of coronary artery calcium (CAC) score screening for cardiovascular disease among asymptomatic patients, and this evidence demonstrates that scanning has incremental predictive accuracy above traditional risk factor measurement. However, evidence from high quality studies that demonstrate that the use of CAC score measurement in clinical practice leads to changes in patient management or in individual risk behaviors that improve cardiac outcomes is lacking.
At least 1 randomized controlld trial suggests that the use of CAC score measurement in clinical practice may be associated with improved cardiac risk profiles, but an association between CAC score measurement with improved outcomes has not yet been demonstrated in other studies. CAC scoring has a potential role as a diagnostic test to rule out coronary artery disease (CAD) in patients presenting with symptoms or as a “gatekeeper” test before invasive imaging is performed. Evidence from retrospective studies suggests that negative results on CAC scoring rules out coronary artery disease with good reliability,and at least 1 prospective study suggests that CAC score can be used in an emergency setting to stratify patients for further testing. However, further prospective trials would be needed to demonstrate that such a strategy is effective in practice and is at least as effective as alternate strategies for ruling out CAD. To demonstrate that use of calcium scores improves the efficiency or accuracy of the diagnostic workup of symptomatic patients, rigorous studies that define exactly how coronary calcium scores are used in combination with other tests in the triage of patients would be necessary. Retrospective and prospective studies have been mixed in their findings about whether CAC scores add incremental predictive value to cardiac computed tomography angiography findings in predicting outcomes for symptomatic patients with possible CAD.
Because of the lack of high-quality evidence demonstrating improved outcomes from the use of CAC score either as a screening test to risk stratify patients or as a diagnostic test to in symptomatic patients, the use of coronary artery calcium scoring is considered investigational.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in
the Category Search on the Medical Policy search page.
Applicable codes: S8092, 75571
ICD-10 CODE DESCRIPTION
I20.1 - I20.9 - Opens in a new window Angina pectoris with documented spasm - Angina pectoris, unspecified
I25.10 - I25.119 - Opens in a new window Atherosclerotic heart disease of native coronary artery without angina pectoris - Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.41 - I25.739 - Opens in a new window Coronary artery aneurysm - Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 - I25.759 - Opens in a new window Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 - I25.810 - Opens in a new window Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm - Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 - I25.9 - Opens in a new window Chronic total occlusion of coronary artery - Chronic ischemic heart disease, unspecified
I48.0 - I48.92 - Opens in a new window Paroxysmal atrial fibrillation - Unspecified atrial flutter
Q20.0 - Q25.0 - Opens in a new window Common arterial trunk - Patent ductus arteriosus
Q25.3 - Q26.4 - Opens in a new window Supravalvular aortic stenosis - Anomalous pulmonary venous connection, unspecified
Q26.8 Other congenital malformations of great veins
R06.02 Shortness of breath
R07.2 Precordial pain
R94.30 - R94.39 - Opens in a new window Abnormal result of cardiovascular function study, unspecified - Abnormal result of other cardiovascular function study
Z01.810 Encounter for preprocedural cardiovascular examination
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Malignant hypertensive heart disease
Benign hypertensive heart disease
Unspecified hypertensive heart disease
Intermediate coronary syndrome
Acute coronary occlusion without myocardial infarction
Old myocardial infarction
Other and unspecified angina pectoris
Coronary atherosclerosis due to lipid rich plaque
Other forms of chronic ischemic heart disease
Acute cor pulmonale
Other pulmonary embolism and infarction
Primary pulmonary hypertension
Chronic pulmonary embolism
Dissection of aorta thoracic
Thoracic aneurysm ruptured
Pulmonary insufficiency following trauma and surgery
Transposition of great vessels
Other transposition of great vessels
Bulbus cordis anomalies and anomalies of cardiac septal closure
Endocardial cushion defects
Other endocardial cushion defects
Bulbus cordis anomalies and anomalies of cardiac septal closure
Anomalies of pulmonary valve
Other anomalies of pulmonary valve
Other congenital anomalies of heart
Other specified anomalies of heart
Other specified anomalies of heart
Unspecified anomalies of heart
Patent ductus arteriosus
Coarctation of aorta
Other congenital anomalies of aorta
Other anomalies of aorta
Anomalies of pulmonary artery
Congenital anomaly of great veins
Other anomalies of great veins
Other chest pain
Cardiovascular - nonspecific abnormal results of function studies
Pre-operative cardiovascular examination
Note: Use V72.81* to report preoperative examinations prior to non-coronary cardiac procedures in patients at low risk of coronary artery disease along with 427.31 (atrial fibrillation).
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
- A formal written report with clear identifying demographics and the name of the interpreting provider.
- Reason for the test.
- An interpretive report including image copies.
- Computerized data including image reconstruction.