Cardiovascular Stress Testing - CPT code 93015, 93016, 93017 and lexiscan

Procedure code and description

93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision; with interpretation and report)

93016 Stress test ...supervision only, without interpretation and report $23



93017: Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report  $40

93018: Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic  monitoring, and/or pharmacological stress; interpretation and report only

J2785 Injection, regadenoson, 0.1 mg $52.621

 Lexiscan is supplied as a standard-dose prefilled syringe: Injection solution containing regadenoson 0.4 mg/5 mL (0.08 mg/mL). To report 0.4 mg, or standard-dose prefilled syringe, it is important to code for “4” units

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:
  • 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.
  • 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.
  • Contraindications to pharmacologic stress testing:
    • Dobutamine is contraindicated in patients with:
      1. Idiopathic subaortic stenosis.
      2. Known hypersensitivity to dobutamine.
    • Dipyridamole is contraindicated in patients with:
      1. Known hypersensitivity to dipyridamole.
      2. Dipyridamole is relatively contraindicated in patients with:
        • Known bronchospastic lung disease (asthma).
    • Adenosine is contraindicated in patients with:
      1. Second- or third-degree Atrioventricular (AV) block.
      2. Sinus node disease, except those with a functioning pacemaker.
      3. Known hypersensitivity to adenosine.
    • Regadenoson is contraindicated in patients with:
      1. Second- or third-degree Atrioventricular (AV) block.
      2. Sinus node disease, except those with a functioning pacemaker.
      3. Known hypersensitivity to regadenoson.
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:
  • 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.
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 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.
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

Billing and Coding Guidelnes

CR5015 instructs that, effective for claims received on or after July 1, 2006:

• When your carrier receives a claim for a service with a PC/TC of 4, except for CPT Code 93015; and

• The service is provided in a HPSA or PSA bonus payment area; then

• Your claim will be accepted.

The bonus payment amount is calculated based on the payment amount for the associated professional component code


Your carrier will make any necessary revision to their systems to be able to calculate the bonus payment just for the professional component of the service.

This action will be taken for bonuses paid automatically as well as bonuses paid based on the submission of the QB, QU, AR, or AQ modifiers.

Because there are two associated professional components to 93015, your carrier will follow the instructions in the Medicare Claims Processing Manual and return claims for 93015 as unprocessable. The services must then be resubmitted as separate components in order to receive the bonus on the appropriate professional component.


Carriers will continue to allow the option of withholding HPSA/PSA bonuses if that is requested by physicians and the carriers will not pay the bonus on PCTC 4 to physicians who have already notified them of their decision to not receive hPSA/PSA bonuses.

Example : Column 1 Code / Column 2 Code - 93015/93040

>CPT Code 93015 – Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report

>CPT Code 93040 – Rhythm ECG, one to three leads; with interpretation and report Modifier 59 may be reported if the rhythm ECG is performed at a different encounter than the cardiovascular stress test. If a rhythm ECG is performed during the cardiovascular stress test encounter, CPT code 93040 should not be reported and modifier 59 should not be used.


Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day 

Rationale

Anthem Central Region does not bundle 93017 with 93016. Based on The American College of Cardiology, Guide to CPT 2001,

"Code 9315 describes the complete service including physician supervision of the test and interpretation of the results. 93015 is used to report providing a stress test by a physician in an office or other setting with physician-owned equipment. A physician providing the complete service in a hospital or other setting with institution-owned equipment should report codes 93016 and 93018. Code 93016 alone is used to report supervision of a stress test in circumstances where another physician provides the interpretation and report. The technical component {tracing only} is described by code 93017. Use code 93018 for only the interpretation and report of an exercise stress test." 


Therefore, if 93017 is submitted with 93016--both reimburse separately and if 93017 is submitted with 93018--both reimburse separately. 

Which modifier can I use when billing 93010, 93016, 93018, and 78452?


Medicare denied 93010, 93016, and 93018 because, the procedure or the procedure with a modifier are not compatible


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

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.

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