Pulmonary Stress Testing CPT 94620, 94621


Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed, conditions. The pulmonary stress test will be considered medically necessary for these conditions:
  • To determine whether the patient’s exercise intolerance is related to pulmonary disease and not cardiac disease, lack of conditioning or poor effort.
  • Initial diagnostic workup, when symptoms, generally dyspnea, are out of proportion to findings on static function (spirometry, lung volume and diffusion capacity).
  • Detection of interstitial lung disease (fibrosis) or exercise-induced bronchospasm, which are only manifested by exercise.
  • To evaluate patient's response to a newly established pulmonary treatment regimen.
Abnormal results on the Stage I protocol may indicate that more precise information is required through more complex Stage 2 protocols. If Stage 3 protocols are implemented, arterial blood analysis is necessary. In 75 percent of patients, Stage 1 is sufficient. To determine the oxygen needs for improving exercise tolerance and increased functional capacity, oxygen titration can be done during graded exercise. Absolute contraindications to exercise testing include:
  • Acute febrile illness.
  • Pulmonary edema.
  • Systolic BP > 250 mm Hg.
  • Diastolic BP > 120 mm Hg.
  • Acute asthma attack.
  • Unstable angina.
  • Acute myocarditis.
Limitations:
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.
11X, 12X, 13X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue 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 Publication 100-04, Claims Processing Manual, for further guidance.
046X, 0410, 0412 and 0419
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
94620©
Pulmonary stress test/simple
94621©
Pulm stress test/complex
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 94620 and 94621:
Covered for:
135
Sarcoidosis
162.0
Malignant neoplasm of trachea
162.2–162.5
Malignant neoplasm of trachea, bronchus, and lung
162.8–162.9
Malignant neoplasm of trachea, bronchus, and lung
197.0
Secondary malignant neoplasm of lung
197.3
Secondary malignant neoplasm of other respiratory organs
212.2–212.3
Benign neoplasm of respiratory and intrathoracic organs
231.2
Carcinoma in situ of bronchus and lung
415.0
Acute cor pulmonale
415.11–415.12
Pulmonary embolism and infarction
415.19
Other pulmonary embolism and infarction
446.20
Hypersensitivity angiitis, unspecified
466.0
Acute bronchitis
466.11
Acute bronchiolitis due to Respiratory Syncytial Virus (RSV)
466.19
Acute bronchiolitis due to other infectious organisms
490
Bronchitis, not specified as acute or chronic
491.0–491.1
Chronic bronchitis
491.20–491.22
Obstructive chronic bronchitis
491.8–491.9
Chronic bronchitis
492.0
Emphysematous bleb
492.8
Other emphysema
493.00–493.02
Extrinsic asthma
493.10–493.12
Intrinsic asthma
493.20
Chronic obstructive asthma, unspecified
493.22
Chronic obstructive asthma, with (acute) exacerbation
493.81–493.82
Other forms of asthma
493.90–493.92
Asthma, unspecified
494.0
Bronchiectasis, without acute exacerbation
495.0–495.9
Extrinsic allergic alveolitis
496
Chronic airway obstruction, not elsewhere classified
500
Coal worker’s pneumoconiosis
501
Asbestosis
502
Pneumoconiosis due to other silica or silicates
503
Pneumoconiosis due to inorganic dust
504
Pneumopathy due to inhalation of other dusts
505
Pneumoconiosis, unspecified
508.0–508.1
Respiratory conditions due to other and unspecified external agents
508.8–508.9
Respiratory conditions due to other and unspecified external agents
515
Postinflammatory pulmonary fibrosis
517.1–517.2
Lung involvement in conditions classified elsewhere
517.8
Lung involvement in other diseases classified elsewhere
518.0–518.3
Other diseases of lung
518.5–518.6
Other diseases of lung
518.81–518.84
Other diseases of lung
518.89
Other diseases of lung, not elsewhere classified
519.11
Acute bronchospasm
519.19
Other diseases of trachea and bronchus
519.4
Disorders of diaphragm
519.8
Other diseases of respiratory system, not elsewhere classified
714.81
Rheumatoid lung
737.30
Kyphoscoliosis and scoliosis
780.51
Insomnia with sleep apnea
780.53
Hypersomnia with sleep apnea
780.57
Other and unspecified sleep apnea
786.02
Dyspnea and respiratory abnormalities
786.03–786.07
Apnea
786.09
Other dyspnea and respiratory abnormality
786.2
Cough
786.30
Hemoptysis, unspecified
786.39
Other hemoptysis
793.1
Nonspecific (abnormal) findings on radiological and other examination of lung field
V72.82
Preoperative respiratory examination
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Medical record documentation must indicate the medical necessity for performing the test. Documentation that the service and all it components were performed, including the results of the pulmonary stress test, should be available. This information is normally found in the office notes, progress notes, history and physical, and/or hard copy of the test results.
If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretations, along with copies of the ordering/referring physician’s order for the studies. The physician must indicate the clinical indication/medical necessity for the study in his order for the test.

1 comment:

Monserrat Smith said...

Hey I just came through your blog its really nice blog. you share some good news here on Pulmonary Edema/stress. It is a big issue today.
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump blood to the body efficiently, it can back up into the veins that take blood through the lungs to the left side of the heart.
As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. This fluid reduces normal oxygen movement through the lungs. This and the increased pressure can lead to shortness of breath.
Pulmonary Edema Causes


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