Procedure Codes And Description
Group 1 Codes:
83880 Assay of NATRIURETIC PEPTIDE
Coverage Indications, Limitations, and/or Medical Necessity
B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume expansion and pressure overload, conditions often present in congestive heart failure (CHF). Used in conjunction with other clinical information, measurement of BNP levels (either total or N-terminal) is useful in rapidly establishing or excluding the diagnosis or worsening of CHF in patients with acute exacerbation of dyspnea. Also, BNP levels determined in the first few days after an acute coronary syndrome or event (ACS) may be useful in the prediction of longer-term cardiovascular risk but this risk assessment does not change the management of ACS and is non-covered by regulation.
BNP measurements may be considered reasonable and necessary when used in combination with other medical data such as medical history, physical examination, laboratory studies, and chest x-ray.
•to diagnose or to differentiate heart failure from other potential clinical conditions if the patient’s signs and/or symptoms are consistent with both heart failure and one or more other conditions, e.g., acute dyspnea in a patient with known or suspected pulmonary disease.
•to diagnose or differentiate worsening heart failure if use of the test replaces other diagnostic tests, such as chest film; and/or to confirm the diagnosis when other diagnostic tests are equivocal.
•BNP measurements must be assessed in conjunction with standard diagnostic tests, medical history and clinical findings. The efficacy of BNP measurement as a stand-alone test has not been established yet.
•BNP measurements for monitoring and management of CHF are non-covered. Treatment guided by BNP has not been shown to be superior to symptom-guided treatment in either clinical or quality-of-life outcomes.
•The efficacy but not the utility of BNP as a risk stratification tool (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina) has been established. However, the assessment of BNP level has not been shown to alter patient management. The BNP is not sufficiently sensitive to either preclude or necessitate any other evaluation or treatment in this group of patients.
•Screening examinations are statutorily non-covered.
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.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital - Laboratory Services Provided to Non-patients
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
072x Clinic - Hospital Based or Independent Renal Dialysis Center
085x Critical Access Hospital
999x Not Applicable
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.
Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC.
0300 Laboratory - General Classification
0301 Laboratory - Chemistry
0520 Freestanding Clinic - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0523 Freestanding Clinic - Family Practice Clinic
0525 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility
Congestive Heart Failure (CHF) is a complex clinical syndrome characterized by dysfunction of the left, right, or both ventricles, which results in the impairment of the heart’s ability to circulate blood at the rate sufficient to maintain the metabolic needs of the peripheral tissues and various organs. B-type natriuretic peptide (BNP) is synthesized, stored, and released primarily by the ventricular myocardium in response to volume expansion and pressure overload, which are hemodynamic parameters in CHF. Used in conjunction with other clinical information, serum BNP concentrations parallel dyspnea in heart failure suggesting its usefulness as a neurohormonal index of progressive heart failure. Serum BNP, for the purposes of coverage, is considered a ‘point-of-service test (performed and immediately used in the disposition of patient care).
Serum BNP, when used in conjunction with other clinical information, will be considered reasonable and necessary for the following:
Establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea.
Predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. Since this situation is an inpatient service, it is not addressed in this LCD.
Serum BNP will be considered noncovered in the following:
Monitoring the efficiency of treatment for CHF
Tailoring the therapy for heart failure
Since BNP is a point of service test, the primary outpatient site of service expected to perform a serum BNP is the emergency room or a physician’s office.
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I16.0 Hypertensive urgency
I16.1 Hypertensive emergency
I31.1 Chronic constrictive pericarditis
I42.0 Dilated cardiomyopathy
I42.5 Other restrictive cardiomyopathy
I42.8 Other cardiomyopathies
I50.1 Left ventricular failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.9 Heart failure, unspecified
J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
J45.901 Unspecified asthma with (acute) exacerbation
J98.01 Acute bronchospasm
R06.00 Dyspnea, unspecified
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.82 Tachypnea, not elsewhere classified