Cardiovascular stress testing is a non-invasive diagnostic test performed to evaluate a patient for coronary artery disease (CAD), the severity of CAD, exercise-related arrhythmias or hemodynamic changes and/or cardiac functional capacity for heart transplant candidates. During exercise the heart and body respond to the stress of physical activity. When the heart is diseased, an abnormal response to stress occurs. A stress test is performed with the use of physiological monitoring (including ECG, B/P, heart rate, etc.) during and after the use of a cardiac stressor (exercise or drug). A physician monitors the patient’s response to the stress and makes a diagnostic determination.
Exercise stress testing is considered the standard of care for most patients when stress testing is indicated. Exercise may be in the form of a treadmill, bicycle or other exercise method. When the patient is unable to perform exercise (e.g., is unable to walk), pharmacological stress is utilized. Pharmacological stress is typically performed with the use of dipyridamole, adenosine or dobutamine.
Cardiovascular stress testing is considered adjunctive to the history and physical examination in the diagnosis and treatment of heart disease.Indications
Cardiovascular stress testing is covered by Medicare when reasonable and necessary and in the absence of absolute contraindications. The safety of the patient must be assured.
Covered indications for cardiovascular stress testing include, but are not limited to the following:
Exercise stress testing is considered the standard of care for most patients when stress testing is indicated. Exercise may be in the form of a treadmill, bicycle or other exercise method. When the patient is unable to perform exercise (e.g., is unable to walk), pharmacological stress is utilized. Pharmacological stress is typically performed with the use of dipyridamole, adenosine or dobutamine.
Cardiovascular stress testing is considered adjunctive to the history and physical examination in the diagnosis and treatment of heart disease.Indications
Cardiovascular stress testing is covered by Medicare when reasonable and necessary and in the absence of absolute contraindications. The safety of the patient must be assured.
Covered indications for cardiovascular stress testing include, but are not limited to the following:
- Evaluation of patients with a high likelihood of Coronary Artery Disease (CAD):
- Angina.
- Arrhythmia (e.g., patients presenting with ventricular tachycardia, ventricular fibrillation).
- Syncope.
- Heart failure, including pulmonary edema.
- Arrhythmias in patients with exercise-induced presyncope or syncope.
- Significant vascular obstructive disease indicative of coexistence of occult coronary artery disease (e.g., carotid obstructive disease, peripheral vascular disease involving the lower extremities, abdominal aortic aneurysm).
- Evaluation of the prognosis and severity of disease:
- Known CAD:
- Prior to major surgery for evaluation of risk of anesthesia and surgical intervention.
- When the patient’s individual clinical situation indicates there is high likelihood of progression of disease requiring changes in treatment.
- Stable Angina – As an initial evaluation of drug management.
- Post-MI – The post-MI evaluation is limited by the severity of the disease.
- Post-PTCA – The use of stress testing may be required when the patient is symptomatic after restenosis. This is typically within a six-month period. After six months, symptoms are not typically considered in the post-PTCA period. This would be considered a new episode of illness.
- Post-CABG – The use of stress testing may be required when the patient is symptomatic, if the patient has had a previous “silent” (asymptomatic) ischemic event or to evaluate the rehab plan for the patient.
- Known CAD:
- Evaluation of functional capacity:
- Valvular heart disease.
- Cardiomyopathy.
- Status post-intervention or drug change in patient with known CAD.
- Evaluate potential heart transplant candidates.
- Evaluate the effects of therapy/interventions:
- The patient’s clinical situation is the key in the determination for the necessity of testing and the appropriate frequency.
- The absence of symptoms (e.g., angina) prior to known cardiac event (e.g., past silent MI) indicates that future events may be asymptomatic. Therefore, testing is appropriate at a frequency established by the patient’s individual clinical situation.
Limitations
Non-Covered indications include:
- Screening for coronary disease; the presence of risk factors alone is not a Medicare-payable indication.
- Stimulus to motivate changes in lifestyle (e.g., weight loss or exercise programs do not meet the Medicare medical necessity criteria).
- Sports medicine.
- Routine follow-up tests for MI, CABG or PTCA in the absence of symptoms or clinical indications (e.g., annual stress tests are not covered in the absence of individualized clinical indications).
- Occupational fitness.
Contraindications may include, when used for diagnostic purposes, patients with the following diseases, signs or symptoms:
- Clinically significant acute myocarditis or pericarditis.
- Signs of unstable progressive angina. This includes the patient who has long periods of angina of fairly recent onset while at rest.
- Advanced atrioventricular block or life-threatening arrhythmias.
- Acutely ill patients, such as those with infections, hyperthyroidism or severe anemia.
- Uncompensated severe congestive heart failure.
- Acute aortic dissection.
- Acute pulmonary embolus/infarction.
- Left main coronary artery stenosis.
- Moderate or severe valvular heart disease.
- Electrolyte abnormalities.
- Severe arterial hypertension.
- Tachyarrhythmia/bradyarrhythmia.
- Hypertrophic cardiomyopathy or other forms of outflow obstruction.
- Inability to exercise adequately.
- High-degree atrioventricular block.
Pharmacologic ECG stress testing is indicated only when the patient is unable to exercise adequately for medical reasons. These reasons may include physical limitations (e.g., arthritis, amputation, severe peripheral vascular disease, severe COPD) and those individuals with a baseline left bundle branch block of unknown origin. Documentation in the patient’s record must clearly indicate that the patient is unable to exercise, as well as the reason(s) why the patient cannot undergo exercise stress testing. (A review of records may be performed to determine if drugs are being used appropriately.) The drugs used in cardiovascular testing are potent drugs with many side effects and must be used with appropriate caution.
Stress testing by multiple modalities (e.g., treadmill ECG, echocardiogram, SPECT) for the same clinical event is covered only when the first modality was inconclusive or uninterpretable. Pharmacologic stress agents may be appropriate for those patients who are unable to reach 75–100 percent of their age-predicted maximum heart rate by physiologic exercise. Vasodilation can be achieved with the use of dipyridamole, adenosine and regadenoson. Dobutamine may be used to affect stress through its inotropic effect.
Stress testing by multiple modalities (e.g., treadmill ECG, echocardiogram, SPECT) for the same clinical event is covered only when the first modality was inconclusive or uninterpretable. Pharmacologic stress agents may be appropriate for those patients who are unable to reach 75–100 percent of their age-predicted maximum heart rate by physiologic exercise. Vasodilation can be achieved with the use of dipyridamole, adenosine and regadenoson. Dobutamine may be used to affect stress through its inotropic effect.
- Contraindications to pharmacologic stress testing:
- Dobutamine is contraindicated in patients with:
- Idiopathic subaortic stenosis.
- Known hypersensitivity to dobutamine.
- Dipyridamole is contraindicated in patients with:
- Known hypersensitivity to dipyridamole.
- Dipyridamole is relatively contraindicated in patients with:
- Known bronchospastic lung disease (asthma).
- Adenosine is contraindicated in patients with:
- Second- or third-degree Atrioventricular (AV) block.
- Sinus node disease, except those with a functioning pacemaker.
- Known hypersensitivity to adenosine.
- Regadenoson is contraindicated in patients with:
- Second- or third-degree Atrioventricular (AV) block.
- Sinus node disease, except those with a functioning pacemaker.
- Known hypersensitivity to regadenoson.
- Dobutamine is contraindicated in patients with:
Since these drugs may be billed for indications other than pharmacological stress agents with cardiovascular testing, the use of these drugs is not subject to the diagnoses listed in this policy.
The indications for the use of these drugs must be documented in the patient’s record as well as the appropriate ICD-9-CM code that describes the patient’s condition.
Stress testing is covered only at a frequency appropriate for the patient’s condition. Documentation in the patient’s progress notes must indicate medical necessity for the frequency.
The place of service is limited to an inpatient hospital, outpatient hospital, Independent Diagnostic Testing Facility (IDTF) or in a physician-directed clinic (office).
Cardiac stress testing must be performed under the direct supervision of a physician who provides the following:
The indications for the use of these drugs must be documented in the patient’s record as well as the appropriate ICD-9-CM code that describes the patient’s condition.
Stress testing is covered only at a frequency appropriate for the patient’s condition. Documentation in the patient’s progress notes must indicate medical necessity for the frequency.
The place of service is limited to an inpatient hospital, outpatient hospital, Independent Diagnostic Testing Facility (IDTF) or in a physician-directed clinic (office).
Cardiac stress testing must be performed under the direct supervision of a physician who provides the following:
- Medical expertise required for performance of the test.
- Medical treatment for complications and side effects of the test.
- Medical services required as part of the test such as injections of medications.
- Medical expertise in the interpretation of the test, some of which has to be provided during the test and before the patient is discharged from the testing suite.
Direct supervision requires that the physician is present in the same office or suite as the patient and is immediately available, if needed, for emergencies or questions. The supervising physician is responsible for assuring that the non-physician performing the test is qualified.
Stress testing can be performed in conjunction with other cardiac diagnostic tests when medically necessary, including echocardiography and nuclear medicine studies. The general rules of this policy apply, but refer to those specific policies for details of coverage. Only the most appropriate tests necessary to determine information should be performed.
The Textbook of Cardiovascular Medicine edited by Eric J. Topol, page 1225, reads: “The presence of left bundle branch block, left ventricular hypertrophy with strain, ventricular preexcitation (Wolff-Parkinson-White Syndrome) or permanent ventricular pacing on the ECG are contraindications to use the exercise ECG for diagnostic purposes (emphasis added), due to the uncertain diagnostic value of additional ST segment changes in these settings, but do not preclude use of the ETT [exercise tolerance test] to assess exercise performance or evaluate the risk of arrhythmia when indicated.” This LCD accepts and incorporates the logic of this quotation.
A preoperative cardiovascular stress test is reasonable and necessary only if there is a cardiac condition diagnosed or suspected that may affect the decision to operate or the choice of the operation. That condition must be identified on the claim using an appropriate ICD-9-CM code. If such a condition does not exist, then preoperative testing is considered screening and is not a covered test.
Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
The Textbook of Cardiovascular Medicine edited by Eric J. Topol, page 1225, reads: “The presence of left bundle branch block, left ventricular hypertrophy with strain, ventricular preexcitation (Wolff-Parkinson-White Syndrome) or permanent ventricular pacing on the ECG are contraindications to use the exercise ECG for diagnostic purposes (emphasis added), due to the uncertain diagnostic value of additional ST segment changes in these settings, but do not preclude use of the ETT [exercise tolerance test] to assess exercise performance or evaluate the risk of arrhythmia when indicated.” This LCD accepts and incorporates the logic of this quotation.
A preoperative cardiovascular stress test is reasonable and necessary only if there is a cardiac condition diagnosed or suspected that may affect the decision to operate or the choice of the operation. That condition must be identified on the claim using an appropriate ICD-9-CM code. If such a condition does not exist, then preoperative testing is considered screening and is not a covered test.
Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
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 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.
0482
CPT/HCPCS Codes
Note: | Providers are reminded to refer to the long descriptors of the |
93015© | Cardiovascular stress test |
93016© | Cardiovascular stress test |
93017© | Cardiovascular stress test |
93018© | Cardiovascular stress test |
J0152 | Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds; instead use a9270) |
J1245 | Injection, dipyridamole, per 10 mg |
J1250 | Injection, dobutamine hydrochloride, per 250 mg |
J2785 | Injection, regadenoson, 0.1 mg |
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.
Note: The use of the listed drug codes (J0152, J1245, J1250 and J2785) is not subject to limited coverage as described below.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 93015, 93016, 93017 and 93018:
Covered for:
250.70–250.73 | Diabetes with peripheral circulatory disorders |
388.72 | Referred otogenic pain |
394.0–394.2 | Mitral stenosis |
394.9 | Other and unspecified mitral valve diseases |
395.0–395.2 | Diseases of aortic valve |
395.9 | Other and unspecified rheumatic aortic diseases |
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 tricuspid valve |
397.9 | Rheumatic diseases of endocardium valve unspecified |
398.0 | Rheumatic myocarditis |
398.91 | Rheumatic heart failure (congestive) |
402.00–402.01 | Malignant hypertensive heart disease |
402.10–402.11 | Benign hypertensive heart disease |
402.90–402.91 | Unspecified hypertensive heart disease |
404.00–404.03 | Hypertensive heart and chronic kidney disease, malignant |
404.10–404.13 | Hypertensive heart and chronic kidney disease, benign |
404.90–404.93 | Hypertensive heart and chronic kidney disease, unspecified |
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 episode of care unspecified |
410.60–410.62 | True posterior wall infarction episode of care unspecified |
410.70–410.72 | Subendocardial infarction episode of care unspecified |
410.80–410.82 | Acute myocardial infarction of other specified sites episode of care unspecified |
410.90–410.92 | Acute myocardial infarction of unspecified site episode of care unspecified |
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 other |
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 (wall) |
414.19 | Other aneurysm of heart |
414.2−414.3 | Other forms of chronic ischemic heart disease |
414.8–414.9 | Other forms of chronic ischemic heart disease |
416.0–416.2 | Chronic pulmonary heart disease |
416.8–416.9 | Chronic pulmonary heart diseases |
424.0–424.3 | Other diseases of endocardium |
424.90–424.91 | Endocarditis valve unspecified |
424.99 | Other endocarditis valve unspecified |
425.0–425.9 | Cardiomyopathy |
426.0 | Atrioventricular block complete |
426.10–426.13 | Atrioventricular block, other and unspecified |
426.2–426.3 | Conduction disorders |
426.50–426.54 | Bundle branch block, other and unspecified |
427.0–427.2 | Cardiac dysrhythmias |
427.31–427.32 | Atrial fibrillation and flutter |
427.41–427.42 | Ventricular fibrillation and flutter |
427.60–427.61 | Premature beats unspecified |
427.69 | Other premature beats |
427.81 | Sinoatrial node dysfunction |
427.89 | Other specified cardiac dysrhythmias |
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 | Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect |
429.79 | Certain sequelae of myocardial infarction not elsewhere classified other |
429.81–429.83 | Other ill-defined heart diseases |
429.89 | Other ill-defined heart diseases |
433.10–433.11 | Occlusion and stenosis of carotid artery |
440.0 | Atherosclerosis of aorta |
440.20–440.24 | Atherosclerosis of native arteries of the extremities |
440.9 | Generalized and unspecified atherosclerosis |
441.00–441.03 | Dissection of aorta |
441.2 | Thoracic aneurysm without rupture |
441.4 | Abdominal aneurysm without rupture |
441.7 | Thoracoabdominal aneurysm without rupture |
441.9 | Aortic aneurysm of unspecified site without rupture |
442.0–442.3 | Other aneurysm |
442.81–442.84 | Other aneurysm, of unspecified site |
442.89 | Other aneurysm |
442.9 | Other aneurysm of unspecified site |
443.0 | Raynaud’s syndrome |
443.1 | Thromboangiitis obliterans (buerger’s disease) |
443.21–443.24 | Other arterial dissection |
443.29 | Dissection of other artery |
443.81 | Peripheral angiopathy in diseases classified elsewhere |
443.89 | Other peripheral vascular disease |
443.9 | Peripheral vascular disease unspecified |
446.0 | Polyarteritis nodosa |
719.41–719.43 | Pain in joint |
723.1 | Cervicalgia |
724.5 | Backache unspecified |
729.5 | Pain in limb |
745.0 | Common truncus |
745.10–745.12 | Transposition of great vessels |
745.19 | Other transposition of great vessels |
745.2–745.5 | Bulbus cordis anomalies and anomalies of cardiac septal closure |
745.60–745.61 | Endocardial cushion defects |
745.8 | Other bulbus cordis anomalies and anomalies of cardiac septal closure |
746.02 | Stenosis of pulmonary valve congenital |
746.1–746.6 | Other congenital anomalies of heart |
746.81 | Subaortic stenosis congenital |
746.83 | Infundibular pulmonic stenosis congenital |
746.85–746.86 | Other specified anomalies of heart |
780.2 | Syncope and collapse |
785.0–785.2 | Symptoms involving cardiovascular system |
785.50–785.51 | Shock without mention of trauma |
786.02–786.03 | Dyspnea and respiratory abnormalities |
786.05 | Shortness of breath |
786.09 | Respiratory abnormality other |
786.50–786.51 | Chest pain |
786.59 | Other chest pain |
789.01–789.02 | Abdominal pain |
789.06 | Abdominal pain epigastric |
789.09 | Abdominal pain other specified site |
794.30–794.31 | Nonspecific abnormal results of function studies cardiovascular system |
794.39 | Other nonspecific abnormal function study of cardiovascular system |
995.20–995.21 | Other and unspecified adverse effect of drug, medicinal and biological substance |
995.27 | Other drug allergy |
996.02–996.03 | Mechanical complication of cardiac 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 prosthetic device, implant and graft |
996.83 | Complications of transplanted heart |
V12.53 | Personal history of sudden cardiac arrest |
V15.1 | Personal history of surgery to heart and great vessels presenting hazards to health |
V42.1–V42.2 | Organ or tissue replaced by transplant (heart) |
V42.6 | Lung replaced by transplant |
V43.21–V43.22 | Organ or tissue replaced by other means (heart) |
V43.3 | Heart valve replaced by other means |
V45.81–V45.82 | Other postprocedural status |
V47.2 | Other cardiorespiratory problems |
V58.64 | Long-term (current) use of nonsteroidal anti-inflammatories |
V58.69 | Long-term (current) use of other medications |
V67.09* | Follow-up examination following other surgery |
Note: * For V67.09 – providers must include the date of surgery and the procedure code for the surgery performed in item 19 on the CMS-1500 claim form (or electronic equivalent), for payment. | |
V67.2 | Follow-up examination following chemotherapy |
V67.51 | Follow-up examination following completed treatment with high-risk medication not elsewhere classified |
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 document the elements of the history, examination and/or test results that justify the diagnosis on the claim form. The clinical condition that is claimed to justify this test must be clearly documented in the record.
The rationale for selecting stress imaging instead of conventional stress ECG must be indicated in the record.
The rationale for performing both a stress echocardiogram and stress myocardial perfusion study on an individual patient must be indicated in the record.
The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the record.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
The rationale for selecting stress imaging instead of conventional stress ECG must be indicated in the record.
The rationale for performing both a stress echocardiogram and stress myocardial perfusion study on an individual patient must be indicated in the record.
The rationale for selecting pharmacologic stress rather than exercise stress must be indicated in the record.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.
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