cpt 93701 - Cardiac Output Monitoring by Electrical Bioimpedance - dx 425.1, 425.4

Indications
Cardiac output determined by electrical bioimpedance, also known as Thoracic Electrical Bioimpedance (TEB), is based upon the resistive changes in the thorax to an applied current. A special monitor is designed to measure impedance during the cardiac cycle after the introduction of a high-frequency, low-amplitude current using surface electrodes placed at the base of the neck and the lower chest.
Since impedance changes are related to the flow of blood, both stroke volume and cardiac output can be derived. Related hemodynamic parameters such as cardiac index, index of contractility, acceleration index, thoracic fluid content and systemic vascular resistance can also be subsequently estimated.
CMS National Policy Covered Indications
1. Differentiation of cardiogenic from pulmonary causes of acute dyspnea when medical history, physical examination and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
2. Optimization of Atrioventricular (A/V) interval for patients with A/V sequential cardiac pacemakers when medical history, physical examination and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
3. Monitoring of continuous inotropic therapy for patients with terminal congestive heart failure, when those patients have chosen to die with comfort at home or for patients waiting at home for a heart transplant.
4. Evaluation for rejection in patients with a heart transplant as a predetermined alternative to a myocardial biopsy. Medical necessity must be documented should a biopsy be performed after TEB.
5. Optimization of fluid management in patients with congestive heart failure when medical history, physical examination and standard assessment tools provide insufficient information, and the treating physician has determined that TEB hemodynamic data are necessary for appropriate management of the patient.
CMS National Policy Non-Covered Indications
  1. TEB is non-covered when used for patients:
a. With proven or suspected disease involving severe regurgitation of the aorta.
b. With Minute Ventilation (MV) sensor-function pacemakers, since the device may adversely affect the functioning of that type of pacemaker.
c. During cardiac bypass surgery.
d. In the management of all forms of hypertension (with the exception of drug-resistant hypertension defined as failure to achieve goal blood pressure in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic). Note: This indication is subject to contractor discretion.
  1. All other uses of TEB not otherwise specified remain non-covered.
TrailBlazer Local Non-Covered Indications
All forms of hypertension, including drug-resistant hypertension defined above.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). 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.
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.
12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 77X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
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.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
Revenue codes have not been identified for this procedure since it can be performed in a number of revenue centers within a hospital such as emergency room (450), operation room (360), or a clinic (510). Report this HCPCS codeunder the revenue center where it was performed.
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
93701©
Bioimpedance, cv analysis
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.
Medicare is establishing the following limited coverage for CPT/HCPCS code 93701:
Covered for:
425.1
Hypertrophic obstructive cardiomyopathy
425.4
Other primary cardiomyopathies
425.9
Secondary cardiomyopathy, unspecified
428.0
Congestive heart failure, Unspecified
428.1
Left heart failure
428.20–428.23
Systolic Heart Failure
428.30–428.33
Diastolic Heart Failure
428.40–428.43
Combined systolic and diastolic heart failure
428.9
Heart failure, unspecified
674.50–674.54
Peripartum cardiomyopathy
786.02
Orthopnea
786.05
Shortness of breath
V42.1
Heart transplant
V53.31
Adjustment of cardiac pacemaker
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request.
  • The medical record must show that this modality contributed to the management of the patient The use of bioimpedance must be supported by documented changes in the clinical examination and provide for a level of clinical decision-making beyond the findings of the history and physical examination.
  • A separate report, i.e., separate from the Evaluation and Management (E/M) service documentation, should be available for review. The report should list:
    • Patient demographics including name, age, height, weight and vital signs.
    • Date of the study.
    • Referring physician.
    • Clinical diagnosis.
    • Specific reason for the study (as outlined in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy).
    • Results of the cardiac output, cardiac index, thoracic volume, systemic vascular resistance and index of contractility.
    • Interpretation of the data.
    • The application of the data to the listed clinical problem.
Appendices
N/A
Utilization Guidelines
  • Repeated measurements to monitor acute interventions will only be reimbursed once per day.
  • Cardiac output monitoring by TEB must be ordered by the treating physician who must document that its use aids in the management of the patient.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

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