Alternative Reporting Mechanism - E-prescription

Eligible professionals do not have to enroll or file an intent to participate in the eRx Incentive Program. Professionals who choose to participate by reporting the eRx measure through claims can simply report the G-code on service lines of Medicare Part B Physician Fee Schedule (PFS) professional-services claims.

Beginning with the 2010 eRx Incentive program year, eligible professionals may also qualify to earn an eRx incentive by reporting the eRx measure to a qualified registry. Professionals participating in a registry that self-nominates and qualifies to submit data on behalf of eligible professionals for a particular program year should expect to receive more information from the registry on how to participate. Only registries qualified for the Physician Quality Reporting System are eligible to become qualified for purposes of submitting data on the eRx measure on behalf of eligible professionals.

In addition to the claims-based reporting mechanism and the registry-based reporting mechanism, CMS tested electronic health record (EHR) data submission, in cooperation with EHR vendors. After successful completion of the 2009 Physician Quality Reporting System EHR Testing Program and a determination that there was at least one "qualified" EHR vendor, an eligible professional may potentially be able to earn an eRx incentive payment through the EHR-based reporting mechanism beginning with the 2010 eRx Incentive Program (if the eligible professional is using one of the EHR products that CMS "qualified" in its 2009 Physician Quality Reporting System EHR Testing Program). Only an EHR vendor that is qualified for the Physician Quality Reporting System is eligible to become qualified for purposes of an eligible professional being able to earn an eRx incentive through submission of eRx measure data extracted from a qualified EHR product.

NEW! CMS Is Now Accepting Public Comment on Proposed 2012 Physician Quality Reporting System EHR Measure Specifications

The Centers for Medicare & Medicaid Services (CMS) is now accepting public comment on proposed Electronic Health Record (EHR) Measure Specifications under consideration for possible inclusion in the 2012 eRx Incentive Program for future program years.

2010 eRx Incentive Program

As described in the 2010 Medicare PFS final rule (to view the rule, click on the "Statute/Regulations" link at left), CMS retains the claims-based reporting mechanism. In addition, CMS will accept eRx measure data submitted by a qualified registry on behalf of an eligible professional or eRx measure data extracted from a qualified EHR product. Since only EHR products that are qualified for the Physician Quality Reporting System are eligible to become qualified for the eRx Incentive Program, this was contingent upon the successful completion of our 2009 Physician Quality Reporting System EHR Testing Program, a determination that one or more EHR vendors participating in the 2009 Physician Quality Reporting System EHR Testing Program was "qualified," and one or more qualified Physician Quality Reporting System EHR vendors notified us of their desire to have one or more of their products qualified for purposes of the 2010 eRx Incentive Program.

Registry-Based Submission for 2010 Incentive

To qualify to submit eRx measure data on behalf of eligible professionals seeking eRx incentive payments for 2010, registries must be qualified to submit 2010 Physician Quality Reporting System data on behalf of eligible professionals. To become qualified to submit 2010 Physician Quality Reporting System data on behalf of eligible professionals, and thus, be eligible to become qualified to submit 2010 eRx measure data on behalf of eligible professionals, registries are required to go through a self-nomination and vetting process if they are new to Physician Quality Reporting System registry reporting, or to notify CMS of their desire to continue Physician Quality Reporting System data submission in 2010 if they were qualified in 2009 and successfully submitted their users' quality data. To become qualified, registries must meet certain technical and other requirements specified by CMS.

The document "Registry Requirements for Submission of 2010 Physician Quality Reporting System Data on Behalf of Eligible Professionals" describes the high-level requirements for a registry to qualify to submit under the registry-based reporting alternatives for the 2010 Physician Quality Reporting System. This document also outlines how a registry can become qualified for 2010 Physician Quality Reporting System data submission. Any registry that wants to report the eRx measure for the 2010 eRx Incentive Program also will have to follow the requirements contained in this document. This document provides the data submission specifications for registry-based reporting to be utilized by the qualified registries.

An updated list of registries that have become "qualified" to submit quality data to CMS on behalf of their eligible professionals for 2010 Physician Quality Reporting System. This list consists of qualified registries for the 2008 and 2009 Physician Quality Reporting System that have successfully submitted 2008 Physician Quality Reporting System data on behalf of eligible professionals to us and that have notified us of their desire to submit 2010 eRx measure data on behalf of eligible professionals. Additional registries were added to the list of qualified registries for the 2010 eRx Incentive Program upon completion of the 2010 registry self-nomination process. The self-nomination process to qualify additional registries for the 2010 eRx Incentive Program was completed during summer 2010.

EHR-Based Submission for 2010 Incentive

To qualify to submit eRx measure data on behalf of eligible professionals or group practices seeking eRx incentive payments for 2010, EHR vendors must be qualified to report 2010 Physician Quality Reporting System EHR measures. In early 2010, CMS finished vetting EHR vendors that self-nominated to participate in the 2009 EHR Testing Program. EHR vendors that successfully completed the 2009 EHR Testing Program are qualified to report 2010 Physician Quality Reporting System EHR measures and may potentially be qualified to report the 2010 eRx measure. A list of qualified EHR vendors for the 2010 eRx Incentive Program is posted here.

Qualified Electronic Health Record (EHR) Vendors for 2010 Physician Quality Reporting System and Electronic Prescribing Incentive Programs

An updated list of EHR vendors and their programs that have become "qualified" to submit quality data to CMS by eligible professionals 2010 Physician Quality Reporting System reporting. Each of these EHR vendors has gone through a thorough vetting process for the product and version listed including checking their capability to provide the required Physician Quality Reporting System data elements for 10 Physician Quality Reporting System measures. Some EHRs are also capable of reporting the electronic prescribing measure. In addition to capturing the required data elements for the measure calculation, these "qualified" EHR products can also transmit the required information in the requested file format. While the listed EHR vendors and their EHR products have successfully completed the vetting process, CMS cannot guarantee that any other product or version of software from the listed vendors will be compatible for EHR based submission for Physician Quality Reporting System. Additional 2010 EHR products that passed "qualification" were posted by mid-January 2010.

2011 eRx Incentive Program

EHR-Based Submission for 2011 Incentive

To qualify to report the eRx measure for 2011, EHR vendors will need to be qualified to report 2011 Physician Quality Reporting System EHR measures. EHR vendors who wish to qualify to participate in the 2011 Physician Quality Reporting System EHR program must have submitted a self-nomination letter requesting inclusion in the 2011 Physician Quality Reporting System Testing Process in 2010 by no later than January 31, 2010. The 2011 Physician Quality Reporting System EHR vendor qualification process and requirements for the 2011 Physician Quality Reporting System EHR Testing Process are described in the "Requirements for EHR Vendors to Participate in the 2011 Physician Quality Reporting System EHR Program". Any EHR vendor that wants to report the eRx measure for the 2011 eRx Incentive Program also will need to have followed the requirements contained in this document.

Medicare covered preventive service list

MEDICARE PART B PREVENTIVE SERVICES

Annual Wellness Visit (AWV)a  

Human Immunodeficiency Virus (HIV) Screening

Bone Mass Measurements

Medical Nutrition Therapy (MNT)

Cardiovascular Screening Blood Tests   

Prostate Cancer Screening

Colorectal Cancer Screening

Seasonal Influenza, Pneumococcal, and Hepatitis B Vaccinations andtheir Administration

Counseling to Prevent Tobacco Useb                

Screening Mammography

Diabetes Screening Tests                                

Screening Pap Tests and Pelvic Examination

Diabetes Self-Management Training (DSMT)

Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)c

Glaucoma Screening

Medicare Preventive Service

Components of the IPPE
ACQUIRE BENEFICIARY HISTORY and ELEMENTS

1. Review of beneficiary’s medical and social history
At a minimum, obtain the following:
     Past medical/surgical history (experiences with illnesses, hospital stays, operations, allergies, injuries, and treatments);
     Current medications and supplements (including calcium and vitamins);
     Family history (review of medical events in the family, including diseases that may be hereditary or place the beneficiary at risk);
     History of alcohol, tobacco, and illicit drug use;
     Diet; and
     Physical activities.
2. Review of beneficiary’s potential risk factors for depression and other mood disorders
Use any appropriate screening instrument for persons without a current diagnosis of depression recognized by national professional medical organizations to obtain current or past experiences with depression or other mood disorders.
3. Review of beneficiary’s functional ability and level
of safety
Use any appropriate screening questions or standardized questionnaires recognized by national professional medical organizations to review, at a minimum, the following areas:
Hearing impairment;
Activities of daily living;
Falls risk; and
Home safety.
BEGIN EXAMINATION
ELEMENTS
4. An examination
Obtain the following:
Height, weight, and blood pressure;
Visual acuity screen;
Measurement of body mass index; and
Other factors deemed appropriate based on the beneficiary’s medical and social history and current clinical standards.
5. End-of-life planning
End-of-life planning is a required service, upon the beneficiary’s consent. End-of-life planning is verbal or written information provided to the beneficiary regarding:
The beneficiary’s ability to prepare an advance directive in the case that an injury or illness causes the beneficiary to be unable to make health care decisions; and
Whether or not the physician is willing to follow the beneficiary’s wishes as expressed in the advance directive.
COUNSEL BENEFICIARY
ELEMENTS
6. Education, counseling, and referral based on the previous five components
Based on the results of the review and evaluation services provided in the previous five components, provide education, counseling, and referral as appropriate.
7. Education, counseling, and referral for other
preventive services
Complete a brief written plan, such as a checklist, to be given to the beneficiary for obtaining a screening electrocardiogram (EKG), as appropriate, and the appropriate screenings and other preventive services that are covered as separate Medicare Part B benefits. (See below for a list of Medicare-covered
preventive services.)

Billing CPT 99355 with E & M codes

CPT 99355 with E&M services

CPT-4 Code 99355 To report additional prolonged outpatient E&M services, CPT-4 code 99355 (each additional 30 minutes) must be billed in conjunction with code 99354.

Billing Calculations CPT-4 codes 99354 and 99355 are subject to the least restrictive frequency limitation as the required companion code. To calculate the amount of time that is payable for prolonged outpatient services, take the total face-to-face time and subtract the time of the primary E&M service. The following table may be used to calculate billing for prolonged outpatient E&M services.

.

Time of E&M visit code not included              First hour            Each additional 30 minutes

Less than 30 minutes                                     Not reported                Not reported

30 – 74 minutes                                             99354                         Not reported

75 – 104 minutes                                           99354                         99355

105 – 134 minutes                                         99354                         99355 (quantity of 2)

135 – 164 minutes                                         99354                         99355 (quantity of 3)

165 – 194 minutes                                         99354                          99355 (quantity of 4)



Inpatient ServicesCPT-4 Code 99356 - To report prolonged inpatient E&M services, CPT-4 codes 99356 (inpatient setting; first hour) must be billed in conjunction with one of the following E&M service codes:



Description & CPT-4 Code


Initial hospital care and subsequent hospital care

99221 – 99223

99231 – 99233


Inpatient consultation

99251 – 99255


Nursing facility services

99304 – 99310

Inpatient psychotherapy with E&M component

90822, 90829

Initial preventive physical examination CPT G0402, G0403, G0404, G0405

Notes on Medicare Part B Preventive Services

a For dates of service on or after January 1, 2011, the Affordable Care Act allows for coverage of an Annual Wellness Visit (AWV), providing Personalized Prevention Plan Services (PPPS). For more information, refer to “The ABCs of Providing the Annual Wellness Visit” (ICN 905706) at http://www.cms.gov/MLNProducts/downloads/AWV_QRI_ICN905706.pdf on the Centers for Medicare & Medicaid Services (CMS) website.

b Effective for dates of service on or after August 25, 2010, Medicare provides coverage of counseling to prevent tobacco use.
c A Medicare beneficiary with certain risk factors for AAAs may receive a referral for a one-time preventive ultrasound screening for the early detection of AAAs. Important: Eligible beneficiaries must receive a referral for an ultrasound screening for AAA as a result of an IPPE.
Use the following Healthcare Common Procedure Coding System (HCPCS) codes, listed in the table below, when filing claims for the IPPE.

IPPE HCPCS CODES    BILLING CODE DESCRIPTORS


G0402    Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
G0403    Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretationand report
G0404    Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination
G0405    Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventivephysical examination


Frequently Asked Questions • • •
Is the IPPE the same as a beneficiary’s yearly physical?
No, this exam is a preventive physical exam and not a “routine physical checkup” that some seniors may receive every year or two from their physician or other qualified non-physician practitioner. For a newly enrolled beneficiary, the IPPE is an introduction to Medicare and covered benefits. Medicare does not provide coverage for routine physical exams.

Who can perform the IPPE?
The IPPE must be furnished by either a physician (a doctor of medicine or osteopathy) or a qualified non-physician practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist).

Are clinical laboratory tests part of the IPPE?
No, the IPPE does not include any clinical laboratory tests, but the provider may want to make referrals for such tests as part of the IPPE.

Is there a deductible or coinsurance/copayment for the IPPE?
Coverage for the IPPE is provided as a Medicare Part B benefit. For dates of service prior to January 1, 2011, the annual Medicare Part B deductible is waived for the IPPE (HCPCS code G0402), but the coinsurance or copayment still applies. The deductible still applies to the optional screening
EKG (HCPCS codes G0403, G0404, or G0405). For dates of service on or after January 1, 2011, both the Medicare Part B deductible and the coinsurance or copayment are waived for the IPPE only. Neither is waived for the screening EKG.

If a beneficiary enrolled in Medicare in 2010, can he or she have the IPPE in 2011 if it was not performed in 2010?
A beneficiary, who has not yet had an IPPE and whose initial enrollment in Medicare Part B began in 2010, will be able to have an IPPE in 2011, as long as it is done within 12 months of the beneficiary’s initial Medicare Part B enrollment effective date.

Can a separate Evaluation and Management (E/M) service be billed at the same visit as the IPPE?
Medicare payment can be made for a significant, separately identifiable medically necessary E/M service (Current Procedural Terminology [CPT] codes 99201-99215) billed at the same visit as the IPPE when billed with modifier-25. That portion of the visit must be medically necessary to treat the beneficiary’s illness or injury, or to improve the functioning of a malformed body member.

Medicare IVR - some Facts for Medicare secondary claims

IVR Fact

If the patient does not have an employer insurance plan that is primary to Medicare, the IVR will confirm this information. If the patient is covered under an employer insurance plan, the IVR will confirm the information and provide the effective date along with the employer insurance information. Medicare would be the secondary payer to the employer insurance plan.

However, the IVR statement “Medicare primary” does not negate the fact that the patient could have joined an MA plan that replaces traditional Medicare benefits. When the beneficiary has coverage through an MA plan, this plan is a temporary replacement of his traditional Medicare coverage. When this occurs, the patient will receive a new health insurance card from the MA plan and the traditional Medicare card will become inactive until that plan coverage is terminated.

This scenario can happen frequently and cause unnecessary claim denials because the provider’s office assumes without employer insurance and the IVR statement “Medicare Primary” that the claims should be filed to traditional Medicare. The provider should remain on the IVR and also obtain MA plan eligibility to have a complete picture of the patient’s health care coverage.

In addition to using the IVR, providers can also verify patient eligibility and claim status through an online inquiry process.

Medicare Secondary Payer (MSP)

Providers are required to file claims to Medicare using billing information obtained from the beneficiary to whom the item or service is furnished. Section 1862(b)(6) of the Social Security Act requires all entities seeking payment for any item or service furnished to complete, on the basis of information obtained from the individual to whom the item or service is furnished, the portion of the claim relating to the availability of other health insurance. Any provider who bills Medicare for services rendered to Medicare beneficiaries must determine whether Medicare is the primary payer for those services. Asking Medicare beneficiaries or their representatives questions concerning the beneficiary’s MSP status may accomplish this determination.

To conform to the law and regulations, the provider must verify MSP information prior to submitting a bill to Medicare. Verifying MSP information means confirming that the information furnished about the presence of another payer that may be primary to Medicare is correct, clear, and complete and that no changes have occurred.

The role of Medicare as the secondary payer is similar to the coordination of benefits clause in private health insurance policies. By federal law, Medicare is secondary payer to a variety of government and private insurance benefit plans. Medicare should be viewed as the secondary payer when a beneficiary can reasonably be expected to receive medical benefits through one or more of the following means:

 An Employer Group Health Plan (EGHP) for working aged beneficiaries.

 A Large Group Health Plan (LGHP) for disabled beneficiaries.

 Beneficiaries eligible for End Stage Renal Disease (ESRD).

 Auto/medical/no-fault/liability insurance.

 Veterans Affairs (VA).

  A Workers’ Compensation plan.

 The Federal Black Lung Program.

Any conditional primary payment(s) made by Medicare for services related to an injury is subject to recovery. A conditional payment is a payment made by Medicare for Medicare-covered services where another payer is responsible for payment and the claim is not expected to be paid promptly (i.e., within 120 days from receipt of the claim). Medicare makes conditional payments to prevent the beneficiary from using his own money to pay the claim. However, Medicare has the right to recover any payments. This includes payments that should have been paid under:

 Workers’ Compensation.

  Liability.

  Automobile, medical or no-fault insurance.

Questions that might be asked during patient screening include:

 Are you or your spouse currently working?

 Are you currently receiving any type of employer insurance benefits where you work now?

 Are you covered under group health care from a spouse, parent or guardian’s employer insurance plan?

· Are you receiving any type of medical care that could/should be covered under another insurance (e.g., workers’ compensation claim or liability accident)?

 Do you need treatment as a result of an accident/injury/illness where another person/party should be responsible?

Additional questions that could also be asked:

  Are you currently receiving benefits due to coal miner’s disease or through black lung benefits?

 Are you receiving benefits through the United Mine Workers Association?

 Is your injury/illness the result of a work-related accident?

 Are these services related to an auto/no-fault/liability accident?

 Are you a veteran and will this service be paid for by Veterans Affairs?

 Have you changed from “traditional” Medicare benefits to a Medicare Advantage replacement plan?

Each of these questions will help determine Medicare’s role as an insurance payer. Should Medicare process the claim as primary, as the secondary payer, or not at all due to another payer being responsible for the service(s)?

Supplemental Insurance Benefits

A patient may elect to purchase outside supplemental insurance or retain a secondary insurance plan through some type of retirement package from a previous employer. Both types of plans pay as a secondary or supplemental insurance plan to Medicare.

In some instances Medicare claims can be automatically transferred to the supplemental insurance plan either by an automatic crossover process or a process in place for those insurance plans designated as a Medigap plan. 

Supplemental insurance plans may offer an automatic crossover for those entitled to benefits, which is done through the Coordination of Benefits Contractor (COBC). The supplemental insurance eligibility is loaded into the patient’s national profile, and during claims processing the claim is automatically forwarded to the supplemental insurance for processing. This allows the provider office to file one claim and receive claim processing information from two insurance plans. 

Medigap plans are privately purchased and are designed to supplement Medicare coverage as well. Some Medigap insurance plans offer the same automatic crossover benefits as supplemental insurance plans. If the Medigap insurance does not provide automatic claim transfer, the provider must indicate on each Medicare claim the patient’s Medigap insurance information in order for the processed claim to be sent to the Medigap plan.

Transthoracic Echocardiography (TTE) CPT C8929, C8930,93303 -93351

TTE affords unique insight into cardiac structure and function. It is a non-invasive technique in which pulsed high-frequency sound waves are used to visualize the contours, movements and dimensions of cardiac structures. Ultra-high frequency sound waves are directed toward and reflected by cardiovascular structures. Reflected echoes are translated into electrical impulses for display on a monitor and for recording and storage on either videotape or digital recording.

The most commonly utilized echocardiographic techniques are motion-mode (M-mode) and two-dimensional (2-D) echocardiography.

M-mode echocardiography employs a single pencil-like beam ultrasound view of cardiac structures. This method is especially useful for precisely recording the motion and dimensions of intracardiac structures with respect to time.

Two-dimensional echocardiography employs an ultrasound beam rapidly swept through an arc, producing a cross-sectional or fan-shaped view of cardiac structures. It defines the configuration and changing dimensions of the chambers, dynamic cyclic variation in myocardial thickness and the associated valvular motions throughout the cardiac cycle. This technique is useful for recording lateral motion and providing the correct spatial relationship between cardiac structures.

Doppler examination is a valuable adjunct to a complete echocardiographic examination. The basic principle utilizes the changes in frequency when a transmitted ultrasound wave is reflected from a moving surface, allowing measurement of velocity of movement (i.e., blood flow). Doppler velocity recordings (with volumetric flow calculations) provide an integrated picture of cardiac structure, function and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized.

The rapid and non-invasive acquisition of this information has contributed to exponential application and to potential overutilization. This policy addresses the medically reasonable, necessary and appropriate application of TTE.

Ventricular Function and Cardiomyopathies

Changes in myocardial thickness (hypertrophy and thinning), derived parameters of contractility and in chamber volume and morphology can be quantified and charted over time by TTE. Cardiac responses to changes in volume, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional anomalies to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more-frequent-than-annual examinations.

Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities.

Hypertensive Cardiovascular Disease

Left Ventricular Hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. In individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of LVH. TTE (CPT code 93308) may assist the decision to treat and the formulation of a treatment program. Baseline TTE (CPT code 93308) and periodic serial assessment (no more frequently than annually) would be medically appropriate.

Acute Myocardial Infarction and Coronary Insufficiency

TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. Absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six months and annually thereafter generally provides adequate supplemental data to a thoughtful clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment.

The role for TTE in the emergency room assessment of individuals presenting with chest pain is in evolution. Absent supporting clinical findings of myocardial dysfunction, this application is considered investigational and will be subjected to medical necessity review.

Exposure to Cardiotoxic Agents (Chemotherapeutic and External)

Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered reasonably medically necessary.

Cardiac Transplant and Rejection Monitoring

TTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluation should focus on analysis of ventricular function and the integrity of valvular performance.

TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid may alert to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight weeks following transplant with subsequent decremental frequency. Absent acute rejection episodes, approximately three TTE examinations are typically performed yearly in chronic transplant recipients.

Native Valvular Heart Disease

TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multi-valve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist, especially interventions for mitral stenosis. Absent acute intervention or a discrete change in otherwise stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally, it is not medically reasonable and necessary to repeat these examinations more frequently than annually.

Prosthetic Heart Valves (Mechanical and Bioprostheses)

TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Reassessment following convalescence (three to six months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate.

Acute Endocarditis

TTE can provide diagnostic information. Larger vegetations can be directly visualized. Valvular anatomy and ventricular function may also be directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events, analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves.

Pericardial Disease

A collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually reasonable and medically necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids.

Aortic Pathology

TTE can provide valuable information when acute or chronic aortic pathology is present. However, the posterior window of TEE , coupled with the more posterior position of the thoracic aorta has rendered TEE a more determinative study. Non-invasive TTE remains the study of choice for following chronic aortic pathology when images suitable for serial quantitation can be obtained.

Congenital Heart Disease

In children and small adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and non-invasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation if the frequency exceeds an annual evaluation.

Suspected Cardiac Thrombi and Embolic Sources

TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial interstices and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboemboli (valvular heart disease, arrhythmias, especially atrial fibrillation, cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplemental therapeutic decisional data. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus, and the finding of thrombus or vegetation does not establish a cardiac embolic source. Absent the definition of and serial assessment for regression of potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions.

Cardiac Tumors and Masses

Infiltrative and ventricular tumors and masses can be visualized, their extent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitive
in quantifying mass characteristics (solid, cystic, etc.), extensions and attachments. These acute pathologies are not typically followed serially.

Critically Ill and Trauma Patients

There is a role of echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion or a pericardial effusion may be confirmed.

Pertubations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the exigencies of the clinical milieu.

Ultrasonic equipment is increasingly more compact and portable. Certain highly portable (a.k.a. “hand-held”) scanners possess the same functional capabilities, hence, providing the same diagnostic value as traditional and larger “state of the art” instruments. Other scanners have limited capabilities in terms of providing a permanent record of the examination or reduced functional capability for performing a complete examination. Medicare will not cover studies performed in such a manner that the result constitutes a simple extension of the physical examination. To qualify for Medicare payment, a valid echocardiographic service must meet the following standards, regardless of the size of the instrument used to perform the study:

• Performed for an accepted clinical indication.
• Performed by a properly trained examiner.
• Provide a permanent record of images and findings.
• Provide sufficient information to support diagnostic conclusions in a manner that the results will not require confirmation by repeat examination either by a more qualified examiner or utilizing more sophisticated equipment.
• Provide a complete examination, including all of the services described by the CPT code billed.
• Include a written interpretation and report.

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.

12X, 13X, 18X, 21X, 22X, 23X, 71X, 73X, 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.

0480, 0483

CPT/HCPCS Codes

Note:	Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
C8929	TTE w or wo fol w con, Doppler (OPPS)
C8930	TTE w or w/o contr, cont ECG (OPPS)
93303©	Echo transthoracic
93304©	Echo transthoracic
93306©	Tte w/doppler, complete
93307©	Echo exam of heart
93308©	Echo exam of heart
93320©	Doppler echo exam, heart
93321©	Doppler echo exam, heart
93325©	Doppler color flow add-on
93350©	Echo transthoracic
93351©	Stress tte complete

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 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351, C8929 and C8930:

Covered for:

074.1	Epidemic pleurodynia
074.20–074.23	Coxsackie carditis
086.0	Chagas’ disease with heart involvement
088.81	Lyme disease
093.0	Aneurysm of aorta specified as syphilitic
093.1	Syphilitic aortitis
093.20–093.24	Syphilitic endocarditis
093.81–093.82	Other specified cardiovascular syphilis
093.89	Other specified cardiovascular syphilis
093.9	Cardiovascular syphilis unspecified
098.83–098.85	Gonococcal infection of other specified sites
112.81	Candidal endocarditis
115.03–115.04	Infection of Histoplasma capsulatum
115.13–115.14	Infection of Histoplasma duboisii
130.3	Myocarditis due to toxoplasmosis
135	Sarcoidosis
164.1	Malignant neoplasm of heart
164.8	Malignant neoplasm of other parts of mediastinum
198.89	Secondary malignant neoplasm of other specified sites
212.7	Benign neoplasm of heart
238.8–238.9	Neoplasm of uncertain behavior of other and unspecified sites and tissues
239.89	Neoplasm of unspecified nature of other specified sites
275.01–275.03	Disorders of mineral metabolism
275.09	Other disorders of iron metabolism
276.0–276.4	Disorders of fluid, electrolyte and acid-base balance
276.50–276.52	Volume depletion
276.69	Other fluid overload
276.7–276.9	Disorders of fluid, electrolyte, and acid-base balance
277.30	Amyloidosis, unspecified
277.39	Other amyloidosis
362.30–362.37	Retinal vascular occlusion
368.00	Amblyopia unspecified
391.0–391.2	Rheumatic fever with heart involvement
391.8–391.9	Rheumatic fever with heart involvement
392.0	Rheumatic chorea with heart involvement
393	Chronic rheumatic pericarditis
394.0–394.2	Disease of mitral valve
394.9	Other and unspecified mitral valve diseases
395.0–395.2	Disease 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 other endocardial structures
397.9	Rheumatic diseases of endocardium valve unspecified
398.0	Rheumatic myocarditis
398.90–398.91	Other and unspecified rheumatic heart diseases
398.99	Other rheumatic heart diseases
401.0–401.1	Essential hypertension
401.9	Unspecified essential hypertension
402.00–402.01	Malignant hypertensive heart disease
402.10–402.11	Benign hypertensive heart disease
402.90–402.91	Unspecified hypertensive heart disease
403.00–403.01	Hypertensive chronic kidney disease, malignant
403.10–403.11	Hypertensive chronic kidney disease, benign
403.90–403.91	Hypertensive chronic kidney disease, unspecified
404.00–404.03	Hypertensive heart and chronic kidney disease
404.10–404.13	Hypertensive heart and chronic kidney disease, benign
405.01	Malignant renovascular hypertension
405.09	Other malignant secondary hypertension
405.11	Benign renovascular hypertension
405.19	Other benign secondary hypertension
405.91	Unspecified renovascular hypertension
405.99	Other unspecified secondary hypertension
410.00–410.02	Acute myocardial infarction of anterolateral wall
410.10–410.12	Acute myocardial infarction of other anterior wall
410.20–410.22	Acute myocardial infarction of inferolateral wall
410.30–410.32	Acute myocardial infarction of inferoposterior wall
410.40–410.42	Acute myocardial infarction of other inferior wall
410.50–410.52	Acute myocardial infarction of other lateral
410.60–410.62	True posterior wall infarction
410.70–410.72	Subendocardial infarction
410.80–410.82	Acute myocardial infarction of other specified sites
410.90–410.92	Acute myocardial infarction of unspecified site
411.0–411.1	Other acute and subacute forms of ischemic heart disease
411.81	Acute coronary occlusion without myocardial infarction
411.89	Other acute and subacute forms of ischemic heart disease other
412	Old myocardial infarction
413.0–413.1	Angina pectoris
413.9	Other and unspecified angina pectoris
414.00–414.07	Other forms of chronic ischemic heart disease
414.10–414.12	Aneurysm and dissection of heart
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
415.0	Acute cor pulmonale
415.11–415.12	Acute pulmonary heart disease
415.19	Other pulmonary embolism and infarction
416.0–416.2	Chronic pulmonary heart disease
416.8–416.9	Chronic pulmonary heart disease
417.0–417.1	Other diseases of pulmonary circulation
417.8–417.9	Other diseases of pulmonary circulation
420.0	Acute pericarditis in diseases classified elsewhere
420.90–420.91	Other and unspecified acute pericarditis
420.99	Other acute pericarditis
421.0–421.1	Acute and subacute endocarditis
421.9	Acute endocarditis unspecified
422.0	Acute myocarditis in diseases classified elsewhere
422.90–422.93	Other and unspecified acute myocarditis
422.99	Other acute myocarditis
423.0–423.3	Other diseases of pericardium
423.8–423.9	Other diseases of pericardium
424.0–424.3	Other diseases of endocardium
424.90–424.91	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
426.2–426.4	Conduction disorders
426.50–426.54	Bundle branch block, other and unspecified
426.6–426.7	Conduction disorders
427.0–427.2	Cardiac dysrhythmias
427.31–427.32	Atrial fibrillation and flutter
427.41–427.42	Ventricular fibrillation and flutter
427.5	Cardiac arrest
427.60–427.61	Premature beats
427.69	Other premature beats
427.81	Sinoatrial node dysfunction
427.89	Other specified cardiac dysrhythmias
427.9	Cardiac dysrhythmia unspecified
428.0–428.1	Heart failure
428.20–428.23	Systolic heart failure
428.30–428.33	Diastolic heart failure
428.40–428.43	Combined systolic and diastolic heart failure
428.9	Heart failure unspecified
429.0–429.6	Ill-defined descriptions and complications of heart disease
429.71	Acquired cardiac septal defect
429.79	Certain sequelae of myocardial infarction not elsewhere classified other
429.81–429.83	Other ill-defined heart diseases
429.89	Other ill-defined heart diseases
429.9	Heart disease unspecified
431	Intracerebral hemorrhage
434.00–434.01	Cerebral thrombosis
434.10–434.11	Cerebral embolism
434.90–434.91	Cerebral artery occlusion
435.0–435.3	Transient cerebral ischemias
435.8–435.9	Transient cerebral ischemias
436	Acute but ill-defined cerebrovascular disease
440.20–440.24	Atherosclerosis of native arteries of the extremities
440.29	Other atherosclerosis of native arteries of the extremities
441.00–441.03	Dissection of aorta
441.1–441.7	Aortic aneurysm and dissection
441.9	Aortic aneurysm of unspecified site without rupture
444.21–444.22	Arterial embolism and thrombosis of arteries of the extremities
444.81	Embolism and thrombosis of iliac artery
446.1	Acute febrile mucocutaneous lymph node syndrome (MLNS)
446.7	Takayasu’s disease
458.0	Orthostatic hypotension
458.9	Hypotension unspecified
518.4–518.5	Other diseases of lung
518.7	Transfusion related acute lung injury (TRALI)
518.81–518.84	Other diseases of lung
557.0	Acute vascular insufficiency of intestine
593.81	Vascular disorders of kidney
634.60–634.62	Abortion complicated by embolism
635.60–635.62	Legally induced abortion complicated by embolism
636.60–636.62	Illegal abortion complicated by embolism
637.60–637.62	Legally unspecified type of abortion complicated by embolism
638.6	Failed attempted abortion complicated by embolism
673.20–673.24	Obstetrical blood-clot embolism
674.82	Other complications of puerperium with delivery with postpartum complication
674.84	Other complications of puerperium
710.0–710.1	Diffuse diseases of connective tissues
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
745.69	Other endocardial cushion defects
745.7–745.9	Bulbus cordis anomalies and anomalies of cardiac septal closure
746.00	Congenital pulmonary valve anomaly unspecified
746.01–746.02	Anomalies of pulmonary valve
746.09	Other congenital anomalies of pulmonary valve
746.1–746.7	Other congenital anomalies of heart
746.81–746.85	Other specified anomalies of heart
746.87	Malposition of heart and cardiac apex
746.89	Other specified congenital anomalies of heart
746.9	Unspecified congenital anomaly of heart
747.0	Patent ductus arteriosus
747.10–747.11	Coarctation of aorta
747.20–747.22	Other anomalies of aorta
747.29	Other congenital anomalies of aorta
747.3	Congenital anomalies of pulmonary artery
747.40–747.42	Anomalies of great veins
747.49	Other anomalies of great veins
759.3	Situs inversus
759.82	Marfan syndrome
780.02	Transient alteration of awareness
780.2	Syncope and collapse
780.60–780.62	Fever
782.5	Cyanosis
785.0–785.3	Symptoms involving cardiovascular system
785.50–785.51	Shock without mention of trauma
785.59	Other shock without trauma
786.05	Shortness of breath
786.09	Respiratory abnormality other
786.50–786.51	Chest pain
786.59	Other chest pain
790.7	Bacteremia
794.31	Nonspecific abnormal electrocardiogram (ECG) (EKG)
807.4	Flail chest
861.00–861.03	Heart without mention of open wound into thorax
861.10–861.13	Heart with open wound into thorax
901.0–901.2	Injury to blood vessels of thorax
901.40–901.42	Pulmonary blood vessels
922.1	Contusion of chest wall
958.0–958.1	Certain early complications of trauma
958.4	Traumatic shock
959.11–959.14	Trunk, injury other and unspecified
959.19	Other and unspecified injury of other sites of trunk
960.7	Poisoning by antineoplastic antibiotics
962.0	Poisoning by adrenal cortical steroids
963.1	Poisoning by antineoplastic and immunosuppressive drugs
965.09	Poisoning by other opiates and related narcotics
972.0–972.1	Poisoning by agents primarily affecting the cardiovascular system
980.3	Toxic effect of fusel oil
986	Toxic effect of carbon monoxide
990	Effects of radiation unspecified
994.0	Effects of lightning
994.8	Electrocution and nonfatal effects of electric current
995.1	Angioneurotic edema not elsewhere classified
996.01	Mechanical complication due to cardiac pacemaker (electrode)
996.02–996.04	Mechanical complication of cardiac device, implant and graft
996.61	Infection and inflammatory reaction due to cardiac device implant and graft
996.71	Other complications due to heart valve prosthesis
996.83	Complications of transplanted heart
997.1	Cardiac complications not elsewhere classified
998.0	Postoperative shock not elsewhere classified
998.51	Infected postoperative seroma
998.59	Other postoperative infection
999.31	Infection due to central venous catheter
999.4	Anaphylactic shock due to serum not elsewhere classified
V12.53	Personal history of sudden cardiac arrest
V42.1	Heart replaced by transplant
V42.2	Heart valve replaced by transplant
V43.3	Heart valve replaced by other means
V58.69	Long-term (current) use of other medications
V59.8	Donors of other specified organ or tissue

Medicare is establishing the following additional limited coverage for CPT/HCPCS codes 93303, 93304, 93306, 93307 and 93308:

Covered for:

V58.11	Encounter for antineoplastic chemotherapy and immunotherapy
	Note: Use V58.11 to report baseline echocardiography for left ventricular assessment prior to initiating cancer treatment with a known cardiotoxic agent(s).

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.