Electrocardiogram (ECG or EKG) - CPT 93000, 93005, 93010 - WHEN TO USE

Electrocardiography is a graphic record of electrical potentials produced by cardiac tissue. An electrographic tracing is created when electrical impulses produced by the heart spread to the body surface where they are detected by electrodes connected to a recording device. The ECG specifically addressed in this LCD is the standard 12-lead ECG, with or without a rhythm strip or other special leads. A qualified physician or NPP who is licensed by his state to perform these services must make an interpretation. The recording and interpretation should be part of the patient’s medical record.

The ECG is valuable in the evaluation and management of primary diseases of the heart, pericardium and coronary arteries. Electrocardiography may be useful in management of diseases that are not primarily cardiac but which frequently affect the heart either directly or indirectly. The following are indications for which the ECG is appropriate:

• Cardiac ischemia or infarction (new symptoms or exacerbations of known disease).
• Anatomic or structural abnormalities of the heart such as congenital, valvular or hypertrophic heart disease.
• Rhythm disturbances and conduction system disease.
• Chest and central nervous system trauma.
• Use of medications or exposure to toxic substances that affect the heart.
• Metabolic abnormalities such as hyper/hypokalemia, hyper/hypocalcemia, hyper/hypothyroidism, acidosis, alkalosis.
• Systemic diseases that involve the heart.
• Evaluation and management related to invasive cardiac procedures.
• Evaluation of implanted electronic cardiac pacemakers.
• Preoperative management of selected patients.

Patients with cardiac ischemia often present with chest pain. Not infrequently, patients with cardiac ischemia present with symptoms (including atypical chest discomfort) that are atypical for, but which may actually represent myocardial ischemia or infarction. The ECG may be utilized in the evaluation of patients with chest pain (typical or atypical) or other symptoms that are atypical but may be due to cardiac ischemia when an alternate explanation for the symptoms is not apparent.

Whereas there is no argument that the ECG is an important diagnostic tool, coverage cannot be provided for ECGs performed when there is no clear relationship to treatment or diagnosis of a specific disease or injury, or a sign, symptom or complaint is apparent. Payment for the services affected by this LCD must be made only for those services that directly contribute to the diagnosis and treatment of an individual patient. Services provided that do not directly contribute to the diagnosis or treatment of an individual patient (such as ECGs that are performed routinely upon admission to a facility or routinely performed prior to surgery) are not medically necessary and will be denied when billed and coded appropriately.

Preoperative electrocardiography is an important part of assessment of risk of preoperative cardiac morbidity. Important considerations include patient-specific predictors as well as surgery-specific risks. Medicare coverage of preoperative electrocardiography is limited to those patients who possess one or more patient-specific indicators of increased risk for perioperative cardiac morbidity and who will undergo surgery of high or intermediate risk of cardiac morbidity/mortality. Preoperative ECGs performed in circumstances other than those listed above are considered screening and should be billed accordingly.

Patient-specific predictors are such things as age, absence or presence of cardiac disease or dysfunction, current and recent stability of cardiac symptoms and syndromes, and the absence or presence of comorbid conditions known to increase the risk that undisclosed cardiac disease is present. Surgery-specific risks relate to the type of surgery and its associated degree of hemodynamic stress. High-risk procedures include major emergency surgery, aortic and major vascular surgeries, peripheral vascular surgery and prolonged procedures associated with large fluid shifts or blood loss. Intermediate-risk procedures include carotid endarterectomy, prostate surgery, orthopedic procedures, head and neck procedures, intraperitoneal and intrathoracic surgery. Low-risk procedures include endoscopy, superficial procedures, cataract surgery and breast surgery.

Medicare generally does not cover screening for heart disease. Though performance of a baseline ECG in certain asymptomatic patients is considered by many to be appropriate and standard medical practice, Medicare, by statute, may pay for such an ECG only as part of the one-time “Welcome to Medicare” preventative physical examination afforded by section 611 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. All other electrocardiography performed on asymptomatic individuals is considered screening regardless of the presence of risk factors (for cardiac disease) such as family history, hypertension, diabetes mellitus, hyperlipidemia or advanced age in circumstances where information obtained from the electrocardiogram does not directly affect management of the underlying disease.

Generally, one interpretation should be paid per ECG tracing. ECG interpretations (including “over-readings”) that are not made contemporaneous to patient care and/or that do not directly contribute to the diagnosis and treatment of the individual patient are not covered and should not be billed to Medicare. Examples of such non-covered over-reading services include those that are performed by a physician whether or not that physician is treating the patient in such a manner that the interpretation is unavailable to the treating physician timely for use in decision-making regarding patient care (i.e., interpretations of preoperative tracings that are not available to the surgeon prior to the procedure and interpretations of tracings performed during an Evaluation and Management (E/M) service prompted by acute symptoms that are not available until after the medical decision-making is complete).

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, 75X, 83X, 85X

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.

073X

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
93000©	Electrocardiogram, complete
93005©	Electrocardiogram, tracing
93010©	Electrocardiogram report

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 codes 93000, 93005 and 93010:

Covered for:

002.0	Typhoid fever
005.1	Botulism
017.90–017.96	Tuberculosis of other specified organs
018.00–018.06	Acute miliary tuberculosis
018.80–018.86	Other specified miliary tuberculosis
018.90–018.96	Miliary tuberculosis unspecified
020.2	Septicemic plague
022.3	Anthrax septicemia
032.82	Diphtheritic myocarditis
036.2	Meningococcemia
036.40–036.43	Meningococcal carditis
038.0	Streptococcal septicemia
038.10–038.11	Staphylococcal septicemia
038.19	Other staphylococcal septicemia
038.2–038.3	Septicemia
038.40–038.44	Septicemia due to other gram-negative organisms
038.8–038.9	Septicemia
040.0	Gas gangrene
042	Human immunodeficiency virus (HIV) disease
054.5	Herpetic septicemia
074.21–074.23	Coxsackie carditis
086.0	Chagas' disease with heart involvement
088.81	Lyme disease
093.0–093.1	Cardiovascular syphilis
093.20–093.24	Syphilitic endocarditis
093.81–093.82	Other specified cardiovascular syphilis
093.89	Other specified cardiovascular syphilis
093.9	Cardiovascular syphilism unspecified
098.83–098.85	Gonococcal infection of other specified sites
112.5	Disseminated candidiasis
112.81	Candidal endocarditis
115.03–115.04	Histoplasmosis
115.13–115.14	Histoplasma duboisii
115.93–115.94	Histoplasmosis, unspecified
124	Trichinosis
130.3	Myocarditis due to toxoplasmosis
130.8	Multisystemic disseminated toxoplasmosis
135	Sarcoidosis
163.0–163.1	Malignant neoplasm of parietal pleura
163.8–163.9	Malignant neoplasm of pleura
164.0–164.9	Malignant neoplasm of thymus, heart, and mediastinum
165.0	Malignant neoplasm of upper respiratory tract part unspecified
165.8–165.9	Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
212.4–212.7	Benign neoplasm of respiratory and intrathoracic organs
242.00–242.01	Toxic diffuse goiter
242.10–242.11	Toxic uninodular goiter
242.20–242.21	Toxic multinodular goiter
242.30–242.31	Toxic nodular goiter unspecified
242.40–242.41	Thyrotoxicosis from ectopic thyroid nodule
242.80–242.81	Thyrotoxicosis of other specified origin
242.90–242.91	Thyrotoxicosis without mention of goiter or other cause
243	Congenital hypothyroidism
244.0–244.3	Postsurgical hypothyroidism
244.8–244.9	Acquired hypothyroidism
245.0–245.4	Acute thyroiditis
245.8–245.9	Thyroiditis
250.10–250.13	Diabetes with ketoacidosis
250.20–250.23	Diabetes with hyperosmolarity
250.30–250.33	Diabetes with other coma
250.40–250.43	Diabetes with renal manifestations
250.50–250.53	Diabetes with ophthalmic manifestations
250.60–250.63	Diabetes with neurological manifestations
250.70–250.73	Diabetes with peripheral circulatory disorders
250.80–250.83	Diabetes with other specified manifestations
250.90–250.93	Diabetes with unspecified complication
251.0	Hypoglycemic coma
252.00–252.02	Hyperparathyroidism
252.08	Other Hyperparathyroidism
252.1	Hypoparathyroidism
252.8–252.9	Disorders of the parathyroid gland
255.0	Cushing’s syndrome
255.10–255.14	Hyperaldosteronism
255.2–255.3	Disorders of adrenal glands
255.41-255.42	Corticoadrenal insufficiency
255.5-255.6	Disorders of adrenal glands
255.8–255.9	Disorders of adrenal glands
265.0– 265.2	Beriberi - pellagra
270.0	Disturbances of amino-acid transport
272.0–272.9	Disorders of lipoid metabolism
274.82	Gouty tophi of other sites except ear
275.2–275.3	Disorders of mineral metabolism
275.41–275.42	Disorders of calcium metabolism
275.49	Other disorders of calcium metabolis
276.0–276.4	Disorders of fluid, electrolyte, and acid-base balance
276.52	Hypovolemia
276.69	Other fluid overload
276.7–276.9	Disorders of fluid, electrolyte, and acid-base balance
277.30	Amyloidosis
277.39	Other amyloidosis
277.5	Mucopolysaccharidosis
282.60–282.64	Sickle-cell disease
282.68–282.69	Sickle-cell disease
293.0	Delirium due to conditions classified elsewhere
306.2	Cardiovascular malfunction arising from mental factors
337.00–337.01	Disorders of the autonomic nervous system
337.09	Other idiopathic peripheral autonomic neuropathy
357.6	Polyneuropathy due to drugs
362.30–362.37	Retinal vascular occlusion
390	Rheumatic fever without mention of heart involvement
391.0–391.2	Acute rheumatic endocarditis
391.8–391.9	Acute rheumatic endocarditis
392.0	Rheumatic chorea with heart involvement
392.9	Rheumatic chorea without heart involvement
393	Chronic rheumatic pericarditis
394.0–394.2	Diseases of mitral valve
394.9	Diseases of mitral valve, other and unspecified
395.0–395.2	Diseases of aortic valve
395.9	Diseases of aortic valve, other and unspecified
396.0–396.3	Diseases of mitral and aortic valves
396.8–396.9	Diseases of mitral and aortic valves
397.0–397.1	Diseases of other endocardial structures
397.9	Rheumatic diseases of endocardium, valve unspecified
398.0	Rheumatic myocarditis
398.90–398.91	Other rheumatic heart diseases
398.99	Other rheumatic heart diseases
401.0–401.1	Essential hypertension
401.9	Essential hypertension, unspecified
402.00–402.01	Hypertensive heart disease, malignant
402.10–402.11	Hypertensive heart disease, benign
402.90–402.91	Hypertensive heart disease, unspecified
403.00–403.01	Hypertensive renal disease, malignant
403.10–403.11	Hypertensive renal disease, benign
403.90–403.91	Hypertensive renal disease, unspecified
404.00–404.03	Hypertensive heart and renal disease, malignant
404.10–404.13	Hypertensive heart and renal disease, benign
404.90–404.93	Hypertensive heart and renal disease, unspecified
405.01	Secondary hypertension, malignant, renovascular
405.09	Other malignant secondary hypertension
405.11	Benign renovascular hypertension
405.19	Other benign secondary hypertension
405.91	Unspecified renovascular hypertension
405.99	Other unspecified secondary hypertension
410.00–410.02	Acute myocardial infarction, of anterolateral wall
410.10–410.12	Acute myocardial infarction, of other anterior wall
410.20–410.22	Acute myocardial infarction, of inferolateral wall
410.30–410.32	Acute myocardial infarction, of inferoposterior wall
410.40–410.42	Acute myocardial infarction, of other inferior wall
410.50–410.52	Acute myocardial infarction, of other lateral wall
410.60–410.62	Acute myocardial infarction, true posterior wall
410.70–410.72	Acute myocardial infarction, subendocardial
410.80–410.82	Acute myocardial infarction, of other specified sites
410.90–410.92	Acute myocardial infarction, unspecified site
411.0–411.1	Other acute and subacute forms of ischemic heart disease
411.81	Acute coronary occlusion without myocardial infarction
411.89	Other acute and subacute forms of ischemic heart disease
412	Old myocardial infarction
413.0–413.1	Angina pectoris
413.9	Other and unspecified angina pectoris
414.00–414.07	Coronary atherosclerosis
414.10–414.12	Aneurysm and dissection of heart
414.19	Aneurysm of heart, other
414.2–414.3	Other forms of chronic ischemic heart disease
414.8–414.9	Other forms of chronic ischemic heart disease
415.0	Acute cor pulmonale
415.11–415.12	Pulmonary embolism and infarction
415.19	Other pulmonary embolism and infarction
416.0–416.2	Chronic pulmonary heart disease
416.8–416.9	Chronic pulmonary heart disease
417.0–417.1	Other diseases of pulmonary circulation
417.8–417.9	Other diseases of pulmonary circulation
420.0	Acute pericarditis in diseases classified elsewhere
420.90–420.91	Other and unspecified acute pericarditis
420.99	Other acute pericarditis
421.0–421.1	Acute and subacute endocarditis
421.9	Acute endocarditis, unspecified
422.0	Acute myocarditis in diseases classified elsewhere
422.90–422.93	Acute myocarditis
422.99	Other acute myocarditis
423.0–423.3	Other diseases of pericardium
423.8–423.9	Other diseases of pericardium
424.0–424.3	Other diseases of endocardium
424.90–424.91	Other diseases of endocardium
424.99	Other endocarditis valve unspecified
425.0–425.5	Cardiomyopathy
425.7–425.9	Cardiomyopathy
426.0	Atrioventricular block, complete
426.10–426.13	Atrioventricular block, other and unspecified
426.2–426.4	Conduction disorders
426.50–426.54	Bundle branch block, other and unspecified
426.6–426.7	Conduction disorders
426.81–426.82	Other specified conduction disorders
426.89	Other specified conduction disorders, other
426.9	Conduction disorder, unspecified
427.0–427.2	Cardiac dysrhythmias
427.31–427.32	Atrial fibrillation and flutter
427.41–427.42	Ventricular fibrillation and flutter
427.5	Cardiac arrest
427.60–427.61	Premature beats
427.69	Premature beats, other
427.81	Sinoatrial node dysfunction
427.89	Sinoatrial node dysfunction, other
427.9	Cardiac dysrhythmias, unspecified
428.0–428.1	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
429.0–429.6	Ill-defined descriptions and complications of heart disease
429.71	Acquired cardiac septal defect
429.79	Certain sequelae of myocardial infarction, NEC, other
429.81–429.83	Other ill-defined heart disease
429.89	Other ill-defined heart disease
429.9	Heart disease, unspecified
430	Subarachnoid hemorrhage
431	Intracerebral hemorrhage
432.0–432.1	Other and unspecified intracranial hemorrhage
432.9	Unspecified intracranial hemorrhage
433.00–433.01	Occlusion and stenosis of precerebral arteries, basilar artery
433.11	Occlusion and stenosis of carotid artery with cerebral infarction
433.21	Occlusion and stenosis of vertebral artery with cerebral infarction
433.31	Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction
433.81	Occlusion and stenosis of other specified precerebral artery with cerebral infarction
433.91	Occlusion and stenosis of unspecified precerebral artery with cerebral infarction
434.00–434.01	Occlusion of cerebral arteries, cerebral thrombosis
434.10–434.11	Occlusion of cerebral arteries, cerebral embolism
434.90–434.91	Cerebral artery occlusion, unspecified
435.0–435.3	Transient cerebral ischemia
435.8–435.9	Transient cerebral ischemia
436	Acute but ill-defined cerebrovascular disease
437.0–437.9	Cerebral atherosclerosis
440.9	Generalized and unspecified atherosclerosis
441.00–441.03	Dissection of aorta
441.1–441.7	Aortic aneurysm and dissection
441.9	Aortic aneurysm of unspecified site without rupture
442.89	Aneurysm of other specified site
443.0–443.1	Other peripheral vascular disease
443.21–443.24	Other arterial dissection
443.29	Dissection of other artery
443.81–443.82	Other specified peripherial vascular diseases
443.89	Other peripherial vascular diseases
443.9	Peripherial vascular disease, unspecified
444.0–444.1	Arterial embolism and thrombosis
444.21–444.22	Arterial embolism and thrombosis, of arteries of the extremities
444.81	Embolism and thrombosis of iliac artery
444.89	Embolism and thrombosis of other artery
444.9	Embolism and thrombosis of unspecified artery
446.0–446.1	Polyarteritis nodosa and allied conditions
446.20–446.21	Hypersensitivity angiitis
446.29	Other specified Hypersensitivity angiitis
446.3 –446.7	Polyarteritis nodosa and allied conditions
458.0–458.1	Orthostatic hypotension
458.21	Hypotension of hemodialysis
458.29	Other iatrogenic hypotension
458.8–458.9	Hypotension
491.20–491.22	Obstructive chronic bronchitis
492.0	Emphysematous bleb
492.8	Other emphysema
493.00–493.02	Extrinsic asthma
493.10–493.12	Intrinsic asthma
493.20–493.22	Chronic obstructive asthma
493.81–493.82	Other forms of asthma
493.90–493.92	Asthma unspecified
496	Chronic airway obstruction not elsewhere classified
506.1	Acute pulmonary edema due to fumes and vapors
507.0	Pneumonitis due to inhalation of food or vomitus
511.0–511.1	Pleurisy
511.81	Malignant pleural effusion
511.9	Unspecified pleural effusion
514	Pulmonary congestion and hypostasis
518.2	Compensatory emphysema
518.4–518.5	Other diseases of lung
518.7	Transfusion related acute lung injury
518.81–518.84	Other diseases of lung
519.3	Other diseases of mediastinum not else where classified
530.0	Achalasia and cardiospasm
530.10–530.13	Esophagitis
530.19	Other esophagitis
530.20–530.21	Ulcer of esophagus
530.3–530.5	Diseases of esophagus
530.81	Esophageal reflux
530.86–530.87	Other specified disorders of esophagus
552.3	Diaphragmatic hernia with obstruction
557.0	Acute vascular insufficiency of intestine
569.85	Angiodysplasia of intestine with hemorrhage
577.0	Acute pancreatitis
580.0	Acute glomerulonephritis with lesion of proliferative glomerulonephritis
580.4	Acute glomerulonephritis with lesion of rapidly progressive glomerulonephritis
585.3–585.6	Chronic kidney disease
611.71	Mastodynia
634.50–634.52	Abortion complicated by shock
634.60–634.62	Abortion complicated by embolism
635.50–635.52	Legally induced abortion complicated by shock
635.60–635.62	Legally induced abortion complicated by embolism
636.50–636.52	Illegally induced abortion complicated by shock
636.60–636.62	Illegally induced abortion complicated by embolism
637.50–637.52	Unspecified abortion complicated by shock
637.60–637.62	Unspecified abortion complicated by embolism
638.5–638.6	Failed attempted abortion
639.5–639.6	Complications following abortion and ectopic and molar pregnancies
639.8	Other specified complications following abortion or ectopic and molar pregnancy
642.00– 642.04	Benign essential hypertension complicating pregnancy
642.10–642.14	Hypertension secondary to renal disease complicating pregnancy
642.20–642.24	Other pre-existing hypertension complicating pregnancy
642.30–642.34	Transient hypertension of pregnancy
642.40–642.44	Mild or unspecified pre-eclampsia
642.50 – 642.54	Severe pre-eclampsia
642.60–642.64	Eclampsia
642.70–642.74	Pre-eclampsia or eclampsia superimposed on pre-existing hypertension
642.90–642.94	Unspecified hypertension complicating pregnancy
648.50–648.54	Congenital cardiovascular disorders
648.60–648.64	Other cardiovascular diseases
668.00–668.04	Pulmonary complications
668.11– 668.14	Cardiac complications
669.10–669.14	Shock during or following labor and delivery
669.20–669.24	Maternal hypotension syndrome
669.40–669.44	Other complications of obstetrical surgery and procedures
673.00–673.04	Obstetrical air embolism
673.10–673.14	Amniotic fluid embolism
673.20–673.24	Obstetrical blood-clot embolism
673.30–673.34	Obstetrical pyemic and septic embolism
673.80–673.84	Other and unspecified complications of puerperium, not elsewhere classified
674.80	Other complications of puerperium unspecified as to episode of care
674.82	Other complications of puerperium with delivery with postpartum complication
674.84	Other complications of puerperium
710.0–710.1	Systemic lupus erythematosus
714.0–714.2	Rheumatoid arthritis and other inflammatory polyarthropathies
714.30–714.33	Juvenile chronic polyarthritis
714.4	Chronic postrheumatic arthropathy
714.81	Rheumatoid lung
714.89	Other specified inflammatory polyarthropathies
714.9	Unspecified inflammatory polyarthropathy
719.41–719.43	Pain in joint
724.1	Pain in thoracic spine
729.5	Pain in limb
729.71	Nontraumatic compartment syndrome of upper extremity
729.81–729.82	Other musculoskeletal symptoms referable to limbs
729.89	Other musculoskeletal symptoms referable to limbs
733.6	Tietze’s disease
738.3	Acquired deformity of chest and rib
745.0	Common truncus
745.10–745.12	Transposition of great vessels
745.19	Bulbus cordis anomalies and anomalies of cardiac septal closure, other
745.2–745.5	Bulbus cordis anomalies and anomalies of cardiac septal closure
745.60–745.61	Endocardial cushion defects
745.69	Other endocardial cushion defects
745.7–745.9	Bulbus cordis anomalies and anomalies of cardiac septal closure
746.00–746.02	Other congenital anomalies of heart
746.09	Other congenital anomalies of heart
746.1–746.7	Other congenital anomalies of heart
746.81–746.87	Other specified anomalies of heart
746.89	Other specified anomalies of heart
746.9	Unspecified congenital anomaly of heart
747.0	Patent ductus arteriosis
747.10–747.11	Coartaction of aorta
747.20–747.22	Other congenital anomalies of circulatory system
747.29	Other anomalies of aorta
747.3	Anomalies of pulmonary arteries
747.40–747.42	Anomalies of great veins
747.49	Other anomalies of great veins
754.81–754.82	Other specified nonteratogenic anomalies
780.01–780.03	Alteration of consciousness
780.09	Alteration of consciousness; other
780.1–780.2	General symptoms
780.31–780.33	Convulsions
780.39	Other convulsions
780.4	Dizziness and giddiness
780.50–780.59	Sleep disruptions
780.60–780.61	Fever
780.71	Chronic fatigue syndrome
780.79	Other malaise and fatigue
782.0	Disturbance of skin sensation
782.3	Edema
782.5	Cyanosis
782.61–782.62	Pallor and flushing
784.1	Throat pain
784.92	Jaw pain
785.0–785.4	Symptoms involving cardiovascular system
785.50–785.52	Symptoms involving cardiovascular system, shock without mention of trauma
785.59	Other shock without trauma
785.6	Enlargement of lymph nodes
785.9	Other symptoms involving cardiovascular system
786.00–786.07	Dyspnea and respiratory abnormalities
786.09	Other dyspnea and respiratory abnormalities
786.50–786.52	Other symptoms involving cardiovascular system
786.59	Other chest pain
787.01–787.03	Nausea and vomiting
787.1	Heartburn
789.00–789.07	Abdominal pain
789.09	Abdominal pain other specified site
789.1	Hepatomegaly
790.4	Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (ldh)
793.1–793.2	Nonspecific abnormal findings on radiological and other examinations, lung field
794.30–794.31	Nonspecific abnormal results of function tests, cardiovascular
794.39	Nonspecific abnormal results of function tests, cardiovascular other
796.3	Nonspecific low blood pressure reading
799.01–799.02	Asphyxia and hypoxemia
799.1	Respiratory arrest
807.00–807.09	Rib(s) closed
807.11–807.19	Rib(s) opened
807.2–807.4	Fracture of rib(s), sternum, larynx, and trachea
860.0–860.5	Traumatic pneumothorax and hemothorax
861.00–861.03	Injury to heart without mention of open wound into thorax
861.10–861.13	Injury to heart with open wound into thorax
861.20–861.22	Lung, without mention of open wound into thorax
861.30–861.32	Lung, with open wound into thorax
862.0	Diaphragm, without mention of open wound into cavity
862.21–862.22	Other specified intrathoracic organs, without mention of open wound into cavity
862.29	Other specified intrathoracic organs, without mention of open wound into cavity
862.31–862.32	Other specified intrathoracic organs with open wound into cavity
862.39	Other specified intrathoracic organs with open wound into cavity
862.8–862.9	Injury to multiple and unspecified intrathoracic organs
875.0–875.1	Open wound of chest (wall)
901.0–901.3	Injury to blood vessels of thorax
901.40–901.42	Injury to pulmonary blood vessels
901.81–901.83	Injury to other specified blood vessels of thorax
901.89	Injury to other specified blood vessels of thorax
922.1	Contusion of chest wall
926.8–926.9	Crushing injury to trunk
958.0–958.1	Certain early complications of trauma
958.4	Traumatic shock
959.11–959.12	Injury, other and unspecified, trunk
959.19	Other injury of other sites of trunk
972.0–972.9	Poisoning by agents primarily affecting the cardiovascular system
986	Toxic effect of carbon monoxide
989.3–989.5	Toxic effect of other substances, chiefly non-medicinal as to source
991.6	Hypothermia
992.0–992.1	Effects of heat and light
993.2–993.4	Effects of air pressure
994.0–994.1	Effects of other external causes
994.4–994.5	Effects of other external causes
994.7–994.8	Effects of other external causes
995.0	Other anaphylactic shock
995.4	Shock due to anesthesia
995.60–995.69	Anaphylactic shock due to adverse food reaction
996.00–996.04	Complications peculiar to certain specified procedures
996.09	Mechanical complication of other device, implant, and graft
996.1	Mechanical complication of other vascular device implant and graft
996.61	Infection and inflammatory reaction due to cardiac device, implant, and graft
996.71–996.72	Other complications of internal (biological)(synthetic) prosthetic device, implant and graft
996.83–996.84	Complications of transplanted organ
997.1–997.2	Nervous system complications
997.4	Digestive system complications not elsewhere classified
998.0	Postoperative shock, not elsewhere classified
999.1	Air embolism as a complication of medical care not elsewhere classified
999.4–999.5	Complications of medical care not elsewhere classified
999.9	Other and unspecified complications of medical care not elsewhere classified
V12.53	Personal history of sudden cardiac arrest
V15.1	Personal history of surgery to heart and great vessels
V42.1–V42.2	Organ or tissue replaced by transplant
V43.21–V43.22	Organ or tissue replaced by other means, heart
V43.3–V43.4	Organ or tissue replaced by other means
V45.00–V45.02	Other post-procedural states
V45.09	Cardiac device in situ, other specified cardiac device
V45.81–V45.82	Other post-procedural states
V45.88	Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility
V47.2	Other cardiorespiratory problems
V53.31–V53.32	Fitting and adjustment of other device
V53.39	Fitting and adjustment of cardiac device, other
V58.44	Aftercare following organ transplant
V58.69*	Long-term (current) use of other medications (high-risk medications)
	Note: *May be used, even though the high-risk medication has not been started (is not current).
V67.51	Follow-up examination following completed treatment with high-risk medication not elsewhere classified
V69.4	Lack of adequate sleep
V72.81*–V72.84*	Special investigations and examinations
	Note: *When billing one of these codes, you must also include other ICD-9-CM codes for the medical condition(s) that prompted the surgery or preoperative medical evaluation. The use of these diagnosis codes alone does not establish medical necessity and claims will be denied.

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

One of the following “E” codes may be used as a secondary diagnosis when one of the above ICD-9-CM diagnosis codes is used as the primary diagnosis.

E925.0	Accident caused by domestic wiring and appliances
E925.1	Accident caused by electric current in electric power generating plants distribution stations transmission lines
E925.2	Accident caused by industrial wiring appliances and electrical machinery
E925.8	Accident caused by other electric current
E925.9	Accident caused by unspecified electric current

Note: Use of one of the “E” codes provides further clarification of the need for the procedure but does not affect coverage.

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.
• Documentation should demonstrate that services are provided according to all requirements of this LCD. In this respect, the record should demonstrate the following:
  • Evidence of recent, past, ongoing or suspected cardiac disease or symptoms.
  • For patients in whom the ECG is performed as part of the evaluation of chest pain or symptoms that are atypical for cardiac ischemia, the record must substantiate that the ordering clinician has a valid concern that the etiology of the chest pain or other symptoms is cardiac in origin. Conversely, the record may show that the ECG is being used to exclude cardiac origin for symptoms (including chest pain) for which cardiac origin cannot be excluded by history or physical examination.
  • For serial ECGs, information supporting the medical necessity for repeating the studies at the given interval should be present. Sequential ECGs, either short-term for an acute condition or long-term for a chronic condition, are often appropriate. Documentation must demonstrate that the findings of the test affect management of the condition.
  • The report of the professional component (the interpretation) for the ECG must be a complete written report that includes relevant findings and appropriate comparisons. The interpretation may appear on the actual tracing or with a progress note or other report of an E/M service when the ECG is performed in conjunction with performance of an E/M service. An interpretation reported in the latter fashion, when billed as a separate service from the E/M service, should contain the same information as a report made upon the tracing itself. A simple notation of “ECG/EKG normal,” without accompanying tracing, will not, in this circumstance, suffice as documentation of a separately payable interpretation.
  • Preoperative ECG studies must indicate the underlying cardiac condition or risks, as well as the proposed operation for which cardiac evaluation is being performed. The ECG must be performed reasonably proximate to the proposed surgery to be considered medically necessary.

Appendices

N/A

Utilization Guidelines

Serial ECGs performed over both the short term (as for an acute condition) or over the long term (as for chronic conditions) may be appropriate when performed at a reasonable frequency. However, such ECGs will not be covered by Medicare unless it is clear that the tests are necessary for monitoring an evolving pathologic process for which the therapy will be altered based on the findings of the ECG. The interval between ECGs should be determined by the physician responsible for the patient’s care upon consideration of factors such as natural history and severity of the underlying condition, recent changes in the condition or onset of new symptoms relating to the condition, and/or the specific patient’s historical responses to therapy for his condition.

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.