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.
Cardiac Stress Testing code used
The following is a summary of Current Procedural Terminology (CPT®) codes commonly used for various exercise stress procedures performed with a Midmark cardiac stress testing system. This information is provided only as a guide and is not intended to replace any official recommendations or guidelines, and does not constitute a promise or guarantee by Midmark regarding coverage or payment. Always check with the specific payer for the appropriate use of any CPT or ICD-10 codes. Physician fee schedule values listed are based on a national average and are rounded for brevity. Specific payments vary geographically. Codes and rates are subject to change. It is the responsibility of the provider to determine the correct coding for services provided.
93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report
93016 Stress test …supervision only, without interpretation and report
93017 tracing only, without interpretation and report
93018 interpretation and report only
93320 : echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for electrocardiographic imaging); complete
• Use 93320 in conjunction with 93350, 93351
• Do not report 93320 in conjunction with 93355
93321 : echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study (List separately in addition to codes for ehocardiographic imaging)
• Use 93321 in conjunction with 93350, 93351
• Do not report 93321 in conjunction with 93355
93325 : Echo, Color Doppler Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography)
• Use 93325 in conjunction with 93350, 93351
• Do not report 93325 in conjunction with 93355
93350 : Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report (Do not report in conjunction with 93015)
• Stress testing codes 93016-93018 should be reported, when appropriate, in conjunction with 93350 to capture the cardiovascular stress portion of the study
• Do not report 93350 in conjunction with 93015
93351 : Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional
93352 : Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure]
78451 : Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78452 : Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or distribution and/or rest reinjection
.
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.
Cardiac Stress Testing code used
The following is a summary of Current Procedural Terminology (CPT®) codes commonly used for various exercise stress procedures performed with a Midmark cardiac stress testing system. This information is provided only as a guide and is not intended to replace any official recommendations or guidelines, and does not constitute a promise or guarantee by Midmark regarding coverage or payment. Always check with the specific payer for the appropriate use of any CPT or ICD-10 codes. Physician fee schedule values listed are based on a national average and are rounded for brevity. Specific payments vary geographically. Codes and rates are subject to change. It is the responsibility of the provider to determine the correct coding for services provided.
93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report
93016 Stress test …supervision only, without interpretation and report
93017 tracing only, without interpretation and report
93018 interpretation and report only
93320 : echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for electrocardiographic imaging); complete
• Use 93320 in conjunction with 93350, 93351
• Do not report 93320 in conjunction with 93355
93321 : echocardiography, pulsed wave and/or continuous wave with spectral display; follow-up or limited study (List separately in addition to codes for ehocardiographic imaging)
• Use 93321 in conjunction with 93350, 93351
• Do not report 93321 in conjunction with 93355
93325 : Echo, Color Doppler Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography)
• Use 93325 in conjunction with 93350, 93351
• Do not report 93325 in conjunction with 93355
93350 : Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report (Do not report in conjunction with 93015)
• Stress testing codes 93016-93018 should be reported, when appropriate, in conjunction with 93350 to capture the cardiovascular stress portion of the study
• Do not report 93350 in conjunction with 93015
93351 : Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional
93352 : Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure]
78451 : Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
78452 : Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or distribution and/or rest reinjection
.
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.
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:
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.
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.
CPT/HCPCS Codes
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Note:
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Providers are reminded to refer to the long descriptors of the
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93015©
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Cardiovascular stress test
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93016©
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Cardiovascular stress test
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93017©
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Cardiovascular stress test
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93018©
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Cardiovascular stress test
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J0152
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Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds; instead use a9270)
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J1245
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Injection, dipyridamole, per 10 mg
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J1250
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Injection, dobutamine hydrochloride, per 250 mg
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J2785
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Injection, regadenoson, 0.1 mg
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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.
• Use code 93015 when a practice owns the equipment, performs the procedure and provides the interpretation and written report. This defines the global billing of this study. When not being provided as a global service at an office or imaging center, each portion of the exam is coded separately.
• Use code 93016 when a physician performs/supervises the study but does not issue a report. It is important to understand that a non-physician practitioner (NPP) may perform this test if allowed by scope of practice but may not supervise it under Medicare rules.
• Use code 93017 for the technical portion of the study. When performed in a hospital, this code would be reported on the UB-04 with revenue code 482.
• The physician who interprets and provides a report on the findings of the study assigns code 93018. It is possible for one physician to code both 93016 and 93018 if he or she performs and supervises the test and provides an interpretation and written report. This physician may or may not be the same physician who performs and bills code 78452.
Although the American Medical Association has not yet issued its 2012 CPT manuals, the electronic file is available. It shows that several changes have been made that affect radiology procedures, including nuclear medicine, diagnostic radiology, and interventional radiology.
On the nuclear medicine front, the AMA made a limited series of changes to allow more consistent charging in two areas: hepatobiliary and respiratory procedures.
Should you bill CPT code 93351 instead of 93350 plus 93017?
Specific services, setting determine appropriate code for cardiac stress test
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
93350: Echocardiography, transthoracic, real-time with image documentation (2-D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report
93351: Echocardiography, transthoracic, real-time with image documentation (2-D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision Historically, hospitals have charged 93350 plus 93017 for the stress testing component. Why a hospital reported 93351 instead of 93350 plus 93017? Both of these codes pay the same APC rate. Can you explain how to bill 93351 properly?
First, review the descriptor for 93351 included in your question. CPT 2009 Changes, An Insider’s View states that 93351 “was established to report a stress echocardiogram combined with a complete cardiovascular stress test.”
It further states that: Previously, code 93350 was a stand-alone code. Code 93350 has been revised to support the establishment of a child (indented) code 93351. Code 93350 is used to report the performance and interpretation of a stress echocardiogram only.
Bill codes 93015–93018 if the stress test is performed in a hospital setting, along with procedure code 93350. If the stress test and echocardiogram are performed in an office, bill combined code 93351.
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
Disputed Codes: 78452, A9502, 93017, and J2785
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking additional reimbursement for CPT/HCPCS codes: 78452, A9502, 93017 and J2785.
The Claims Administrator reimbursed the Provider $797.68 for the billed services with the following rationale: The charge exceeds the OMFS allowance. The charge has been adjusted to the scheduled allowance.
UB-04, Bill Type 0131, Revenue Codes: 341, 343, 482 and 636 (CPT 78452, A9502, 93017 and J2785). DOS: 2/19/2015.
Contractual Agreement states the following regarding as being applicable for Group Health, Workers’ Compensation and Other Payment Programs. Hospital Services, all services shall be reimbursed at 90% of Provider’s billed charges. As an Exempt Facility under the California Workers’ Compensation Official Medical Fee Schedule, all Workers’ Compensation services shall be reimbursed under the rates/terms listed above.
The above mentioned contract language was indicated in an “Amendment to Participating Hospital Agreement” submitted by the Provider, effective 8/1/2007 between the PPO Group and the Provider.
The Amendment was signed and dated by both parties.
** § 9789.32 (f) Critical access hospitals and hospitals that are excluded from acute PPS are exempt from this fee schedule.
** Provider is identified on CMS.gov as a Medicare PPS excluded Cancer Hospital.
** Pursuant to LC § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
** § 9792.5.7 (b) Unless as permitted by section 9792.5.12, independent bill review shall only be conducted if the only dispute between the provider and the claims administrator is the amount of payment owed to the provider. Any other issue, including issues of contested liability or the applicability of a contract for reimbursement rates under Labor Code shall be resolved before seeking independent bill review.
** Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for the outpatient hospital services. Reimbursement is recommended based on PPO contract allowance of 90% of the billed charges for CPT/HCPCS codes: 78452, A9502, 93017 and J2785.
Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of exercise stress testing. ICD-10-CM codes and/or ranges are provided below to help with your decision process.
ICD-10-CM Description ICD-10-CM : Code/ Range
Angina pectoris : 120.0-120.9
Atherosclerotic heart disease : I25.10-I25.119
Atrioventricular and left bundle-branch block : 144.0-144.7
Cardiac arrest : I46.2-I46.9
Chronic ischemic heart disease : I25.10-I25.9
Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified : I97.0-I97.89
Myocardial degeneration : I51.5
Nonrheumatic aortic valve disorders : 135.0-135.9
Old myocardial infarction : I25.2
Other acute ischemic heart diseases : I24.0-I24.9
Other conduction disorders : I45.0-145.9
Other congenital malformations of heart : Q24.0-Q24.9
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.
• Use code 93015 when a practice owns the equipment, performs the procedure and provides the interpretation and written report. This defines the global billing of this study. When not being provided as a global service at an office or imaging center, each portion of the exam is coded separately.
• Use code 93016 when a physician performs/supervises the study but does not issue a report. It is important to understand that a non-physician practitioner (NPP) may perform this test if allowed by scope of practice but may not supervise it under Medicare rules.
• Use code 93017 for the technical portion of the study. When performed in a hospital, this code would be reported on the UB-04 with revenue code 482.
• The physician who interprets and provides a report on the findings of the study assigns code 93018. It is possible for one physician to code both 93016 and 93018 if he or she performs and supervises the test and provides an interpretation and written report. This physician may or may not be the same physician who performs and bills code 78452.
Although the American Medical Association has not yet issued its 2012 CPT manuals, the electronic file is available. It shows that several changes have been made that affect radiology procedures, including nuclear medicine, diagnostic radiology, and interventional radiology.
On the nuclear medicine front, the AMA made a limited series of changes to allow more consistent charging in two areas: hepatobiliary and respiratory procedures.
Should you bill CPT code 93351 instead of 93350 plus 93017?
Specific services, setting determine appropriate code for cardiac stress test
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
93350: Echocardiography, transthoracic, real-time with image documentation (2-D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report
93351: Echocardiography, transthoracic, real-time with image documentation (2-D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision Historically, hospitals have charged 93350 plus 93017 for the stress testing component. Why a hospital reported 93351 instead of 93350 plus 93017? Both of these codes pay the same APC rate. Can you explain how to bill 93351 properly?
First, review the descriptor for 93351 included in your question. CPT 2009 Changes, An Insider’s View states that 93351 “was established to report a stress echocardiogram combined with a complete cardiovascular stress test.”
It further states that: Previously, code 93350 was a stand-alone code. Code 93350 has been revised to support the establishment of a child (indented) code 93351. Code 93350 is used to report the performance and interpretation of a stress echocardiogram only.
Bill codes 93015–93018 if the stress test is performed in a hospital setting, along with procedure code 93350. If the stress test and echocardiogram are performed in an office, bill combined code 93351.
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
Disputed Codes: 78452, A9502, 93017, and J2785
ANALYSIS AND FINDING
Based on review of the case file the following is noted:
ISSUE IN DISPUTE: Provider seeking additional reimbursement for CPT/HCPCS codes: 78452, A9502, 93017 and J2785.
The Claims Administrator reimbursed the Provider $797.68 for the billed services with the following rationale: The charge exceeds the OMFS allowance. The charge has been adjusted to the scheduled allowance.
UB-04, Bill Type 0131, Revenue Codes: 341, 343, 482 and 636 (CPT 78452, A9502, 93017 and J2785). DOS: 2/19/2015.
Contractual Agreement states the following regarding as being applicable for Group Health, Workers’ Compensation and Other Payment Programs. Hospital Services, all services shall be reimbursed at 90% of Provider’s billed charges. As an Exempt Facility under the California Workers’ Compensation Official Medical Fee Schedule, all Workers’ Compensation services shall be reimbursed under the rates/terms listed above.
The above mentioned contract language was indicated in an “Amendment to Participating Hospital Agreement” submitted by the Provider, effective 8/1/2007 between the PPO Group and the Provider.
The Amendment was signed and dated by both parties.
** § 9789.32 (f) Critical access hospitals and hospitals that are excluded from acute PPS are exempt from this fee schedule.
** Provider is identified on CMS.gov as a Medicare PPS excluded Cancer Hospital.
** Pursuant to LC § 5307.11: A health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier may contract for reimbursement rates different from those in the fee schedule adopted and revised pursuant to Section 5307.1. When a health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code, and a contracting agent, employer, or carrier contract for reimbursement rates different from those in the fee schedule, the medical fee schedule for that health care provider or health facility licensed pursuant to Section 1250 of the Health and Safety Code shall not apply to the contracted reimbursement rates.
** § 9792.5.7 (b) Unless as permitted by section 9792.5.12, independent bill review shall only be conducted if the only dispute between the provider and the claims administrator is the amount of payment owed to the provider. Any other issue, including issues of contested liability or the applicability of a contract for reimbursement rates under Labor Code shall be resolved before seeking independent bill review.
** Based on the aforementioned documentation and guidelines, additional reimbursement is indicated for the outpatient hospital services. Reimbursement is recommended based on PPO contract allowance of 90% of the billed charges for CPT/HCPCS codes: 78452, A9502, 93017 and J2785.
Report proper ICD-10-CM diagnosis codes to support the medical necessity for the use of exercise stress testing. ICD-10-CM codes and/or ranges are provided below to help with your decision process.
ICD-10-CM Description ICD-10-CM : Code/ Range
Angina pectoris : 120.0-120.9
Atherosclerotic heart disease : I25.10-I25.119
Atrioventricular and left bundle-branch block : 144.0-144.7
Cardiac arrest : I46.2-I46.9
Chronic ischemic heart disease : I25.10-I25.9
Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified : I97.0-I97.89
Myocardial degeneration : I51.5
Nonrheumatic aortic valve disorders : 135.0-135.9
Old myocardial infarction : I25.2
Other acute ischemic heart diseases : I24.0-I24.9
Other conduction disorders : I45.0-145.9
Other congenital malformations of heart : Q24.0-Q24.9
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
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Diabetes with peripheral circulatory disorders
|
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388.72
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Referred otogenic pain
|
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394.0–394.2
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Mitral stenosis
|
|
394.9
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Other and unspecified mitral valve diseases
|
|
395.0–395.2
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Diseases of aortic valve
|
|
395.9
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Other and unspecified rheumatic aortic diseases
|
|
396.0–396.3
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Diseases of mitral and aortic valves
|
|
396.8–396.9
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Diseases of mitral and aortic valves
|
|
397.0–397.1
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Diseases of tricuspid valve
|
|
397.9
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Rheumatic diseases of endocardium valve unspecified
|
|
398.0
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Rheumatic myocarditis
|
|
398.91
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Rheumatic heart failure (congestive)
|
|
402.00–402.01
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Malignant hypertensive heart disease
|
|
402.10–402.11
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Benign hypertensive heart disease
|
|
402.90–402.91
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Unspecified hypertensive heart disease
|
|
404.00–404.03
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Hypertensive heart and chronic kidney disease, malignant
|
|
404.10–404.13
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Hypertensive heart and chronic kidney disease, benign
|
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404.90–404.93
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Hypertensive heart and chronic kidney disease, unspecified
|
|
410.00–410.02
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Acute myocardial infarction of anterolateral wall
|
|
410.10–410.12
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Acute myocardial infarction of other anterior wall
|
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410.20–410.22
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Acute myocardial infarction of inferolateral wall
|
|
410.30–410.32
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Acute myocardial infarction of inferoposterior wall
|
|
410.40–410.42
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Acute myocardial infarction of other inferior wall
|
|
410.50–410.52
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Acute myocardial infarction of other lateral wall episode of care unspecified
|
|
410.60–410.62
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True posterior wall infarction episode of care unspecified
|
|
410.70–410.72
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Subendocardial infarction episode of care unspecified
|
|
410.80–410.82
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Acute myocardial infarction of other specified sites episode of care unspecified
|
|
410.90–410.92
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Acute myocardial infarction of unspecified site episode of care unspecified
|
|
411.0–411.1
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Other acute and subacute forms of ischemic heart disease
|
|
411.81
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Acute coronary occlusion without myocardial infarction
|
|
411.89
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Other acute and subacute forms of ischemic heart disease other
|
|
412
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Old myocardial infarction
|
|
413.0–413.1
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Angina pectoris
|
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413.9
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Other and unspecified angina pectoris
|
|
414.00–414.07
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Coronary atherosclerosis
|
|
414.10–414.12
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Aneurysm and dissection of heart (wall)
|
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414.19
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Other aneurysm of heart
|
|
414.2−414.3
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Other forms of chronic ischemic heart disease
|
|
414.8–414.9
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Other forms of chronic ischemic heart disease
|
|
416.0–416.2
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Chronic pulmonary heart disease
|
|
416.8–416.9
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Chronic pulmonary heart diseases
|
|
424.0–424.3
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Other diseases of endocardium
|
|
424.90–424.91
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Endocarditis valve unspecified
|
|
424.99
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Other endocarditis valve unspecified
|
|
425.0–425.9
|
Cardiomyopathy
|
|
426.0
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Atrioventricular block complete
|
|
426.10–426.13
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Atrioventricular block, other and unspecified
|
|
426.2–426.3
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Conduction disorders
|
|
426.50–426.54
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Bundle branch block, other and unspecified
|
|
427.0–427.2
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Cardiac dysrhythmias
|
|
427.31–427.32
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Atrial fibrillation and flutter
|
|
427.41–427.42
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Ventricular fibrillation and flutter
|
|
427.60–427.61
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Premature beats unspecified
|
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427.69
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Other premature beats
|
|
427.81
|
Sinoatrial node dysfunction
|
|
427.89
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Other specified cardiac dysrhythmias
|
|
428.0–428.1
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Heart failure
|
|
428.20–428.23
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Systolic heart failure
|
|
428.30–428.33
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Diastolic heart failure
|
|
428.40–428.43
|
Combined systolic and diastolic heart failure
|
|
428.9
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Heart failure unspecified
|
|
429.0–429.6
|
Ill-defined descriptions and complications of heart disease
|
|
429.71
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Certain sequelae of myocardial infarction not elsewhere classified acquired cardiac septal defect
|
|
429.79
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Certain sequelae of myocardial infarction not elsewhere classified other
|
|
429.81–429.83
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Other ill-defined heart diseases
|
|
429.89
|
Other ill-defined heart diseases
|
|
433.10–433.11
|
Occlusion and stenosis of carotid artery
|
|
440.0
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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
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Thoracic aneurysm without rupture
|
|
441.4
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Abdominal aneurysm without rupture
|
|
441.7
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Thoracoabdominal aneurysm without rupture
|
|
441.9
|
Aortic aneurysm of unspecified site without rupture
|
|
442.0–442.3
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Other aneurysm
|
|
442.81–442.84
|
Other aneurysm, of unspecified site
|
|
442.89
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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
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Polyarteritis nodosa
|
|
719.41–719.43
|
Pain in joint
|
|
723.1
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Cervicalgia
|
|
724.5
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Backache unspecified
|
|
729.5
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Pain in limb
|
|
745.0
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Common truncus
|
|
745.10–745.12
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Transposition of great vessels
|
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745.19
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Other transposition of great vessels
|
|
745.2–745.5
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Bulbus cordis anomalies and anomalies of cardiac septal closure
|
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745.60–745.61
|
Endocardial cushion defects
|
|
745.8
|
Other bulbus cordis anomalies and anomalies of cardiac septal closure
|
|
746.02
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Stenosis of pulmonary valve congenital
|
|
746.1–746.6
|
Other congenital anomalies of heart
|
|
746.81
|
Subaortic stenosis congenital
|
|
746.83
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Infundibular pulmonic stenosis congenital
|
|
746.85–746.86
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Other specified anomalies of heart
|
|
780.2
|
Syncope and collapse
|
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785.0–785.2
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Symptoms involving cardiovascular system
|
|
785.50–785.51
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Shock without mention of trauma
|
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786.02–786.03
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Dyspnea and respiratory abnormalities
|
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786.05
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Shortness of breath
|
|
786.09
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Respiratory abnormality other
|
|
786.50–786.51
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Chest pain
|
|
786.59
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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
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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.
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 following are considered medically necessary for either the stress echo or SPECT MPI:
1. New, recurrent, or worsening cardiac symptoms AND any of the following:
• Physical inability to perform a maximum exercise workload
• A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or PCI
• Syncope (i.e., no prodromal symptoms, not near syncope) in patients with high likelihood of CAD
• Evidence or high suspicion of ventricular tachycardia
• Age 50 years or greater and known diabetes mellitus
• New or previously unrecognized uninterpretable ECG
• Poorly controlled hypertension, generally, above 180 mm/Hg systolic, if the provider feels strongly that CAD needs evaluation prior to BP being controlled
• ECG is uninterpretable for ischemia due to any one of the following:
o Complete Left Bundle Branch Block (right bundle branch block does not render ECG uninterpretable for ischemia)
o Ventricular paced rhythm
o Pre-excitation pattern such as Wolff-Parkinson-White
o >0.5 mm ST segment depression (NOT nonspecific ST/T wave changes)
o LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria)
o T wave inversion in the inferior and/or lateral leads (leads II, AVF, V5, or V6)
o Patients on digitalis preparations
• Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result
• Patients with recent equivocal or borderline testing where ischemia remains a concern
• Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study
• History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD)
• High pretest probability of CAD (assuming emergency evaluation and/or prompt coronary angiography not previously implemented)
2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin
3. Routine study >3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)
4. Routine study >5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)
5. Every 2 years in patients with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test. Cardiology— non-emergent outpatient testing: exercise stress test, stress echo, MPI SPECT, and cardiac PET.4 Part A/B Form Date: 10/08/13 Page 6 of 26 1-3.2.41 MP Part AB FL Draft LCD
6. To assess for CAD in a patient with unexplained or drug-induced intraventricular condition disturbances
7. Prior anatomic imaging study (coronary angiogram or CCTA) to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging
8. Established CAD in a patient who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable
9. Evaluating new, recurrent, or worsening left ventricular dysfunction/CHF
10. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered
11. Pre-operative cardiac evaluation in patients undergoing non-cardiac surgery -Intermediate risk surgery (cardiac risk 1-5%) one or more cardiac risk factor(s) and inability to exercise adequately -high risk surgery (>5% cardiac risk)
12. Asymptomatic patients with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years
13. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year
14. Patients to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc.
15. Patients with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years
16. Stress echocardiography will be considered reasonable and necessary for the evaluation of valvular heart disease and detection and management of occult pulmonary hypertension.
The following are considered medically necessary for cardiac PET:
1. For the evaluation of coronary artery disease for perfusion of the heart via myocardial perfusion imaging, PET scans using either FDA-approved radiopharmaceutical Rubidium 82 (RB-82) or Ammonia N-13 when performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease, provided the following requirements are met:
a. The PET scan,whether at rest alone or rest with stress, is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT); OR
b. The PET scan,whether at rest alone or rest with stress, is used following a SPECT that was found to be inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an inconclusive test is a test(s) whose results are equivocal, technically uninterpretable, or discordant with a patient’s other clinical data and must be documented in the beneficiary’s file.)
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.
034x Nuclear Medicine – General Classification
048x Cardiology – General Classification
092x Other Diagnostic Services – General Classification
0404 Other Imaging Services – Positron Emission Tomography
This is a vein and vascular center that has multiple locations. They are located in near PHOENIX, ARIZONA, USA. Office locations are, Surprise, Arizona, USA, – Goodyear, Arizona USA, Chandler, Arizona USA and Gilbert , Arizona USA. These cities surround Phoenix, so we want to focus on each city and about a 20 mile radius around each one as well as Phoenix itself since it is in the center of all these cities.