CMS Limitations Guide - Cardiovascular Services

[Pages:2]CMS Limitations Guide - Cardiovascular Services

Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes.

This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: .

CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient's test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses.

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: medicalnecessity.

If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 9357493.

CMS Limitations Guide ? Cardiovascular Services

(L34598) Cardiovascular Stress Testing

PRET (93017) TET (Treadmill) (93017)

CPT Code 93015

93016

93017

93018 93799

Description

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; supervision only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report (PRET) (TET) (Treadmill) Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only Unlisted cardiovascular service or procedure

ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program:

Group 1 Paragraph: Diagnosis codes must be coded to the highest level of specificity. For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

Group 1 Codes:

Code

Description

A18.84

Tuberculosis of heart

E08.00 E08.9

E09.00 E09.9

E10.10 E10.9 E11.00 - E11.9

E13.00 E13.9 I05.0

Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) - Diabetes mellitus due to underlying condition without complications Drug or chemical induced diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) - Drug or chemical induced diabetes mellitus without complications Type 1 diabetes mellitus with ketoacidosis without coma - Type 1 diabetes mellitus without complications Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC) - Type 2 diabetes mellitus without complications Other specified diabetes mellitus with hyperosmolarity without nonketotic hyperglycemichyperosmolar coma (NKHHC) - Other specified diabetes mellitus without complications Rheumatic mitral stenosis

I05.1

Rheumatic mitral insufficiency

I05.2

Rheumatic mitral stenosis with insufficiency

I05.8

Other rheumatic mitral valve diseases

I06.0

Rheumatic aortic stenosis

I06.1

Rheumatic aortic insufficiency

I06.2

Rheumatic aortic stenosis with insufficiency

I08.0

Rheumatic disorders of both mitral and aortic valves

CMS Limitations Guide ? Cardiovascular Services

I08.8 I10 I11.0 I13.0

I13.10

I13.11

I13.2

I20.0 I20.1 I20.8 I21.01 I21.02 I21.09 I21.11 I21.19 I21.21 I21.29 I21.4 I22.0 I22.1 I22.2 I22.8 I24.0 I24.1 I24.8 I25.10 I25.110 I25.111

I25.118 I25.2 I25.5 I25.6

Other rheumatic multiple valve diseases Essential (primary) hypertension Hypertensive heart disease with heart failure Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease Unstable angina Angina pectoris with documented spasm Other forms of angina pectoris ST elevation (STEMI) myocardial infarction involving left main coronary artery ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall ST elevation (STEMI) myocardial infarction involving right coronary artery ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery ST elevation (STEMI) myocardial infarction involving other sites Non-ST elevation (NSTEMI) myocardial infarction Subsequent ST elevation (STEMI) myocardial infarction of anterior wall Subsequent ST elevation (STEMI) myocardial infarction of inferior wall Subsequent non-ST elevation (NSTEMI) myocardial infarction Subsequent ST elevation (STEMI) myocardial infarction of other sites Acute coronary thrombosis not resulting in myocardial infarction Dressler's syndrome Other forms of acute ischemic heart disease Atherosclerotic heart disease of native coronary artery without angina pectoris Atherosclerotic heart disease of native coronary artery with unstable angina pectoris Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris Old myocardial infarction Ischemic cardiomyopathy Silent myocardial ischemia

CMS Limitations Guide ? Cardiovascular Services

I25.710 I25.711

I25.718

I25.720

I25.721

I25.728

I25.730

I25.731

I25.738

I25.750 I25.751

I25.758

I25.760 I25.761

I25.768

I25.790 I25.791

I25.798 I25.810 I25.812 I25.89 I27.0 I27.1 I27.2 I27.81 I27.82 I27.89 I34.0 I34.1 I34.2

Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris

Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris Atherosclerosis of native coronary artery of transplanted heart with unstable angina

Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina

Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris

Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris

Atherosclerosis of coronary artery bypass graft(s) without angina pectoris

Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris

Other forms of chronic ischemic heart disease

Primary pulmonary hypertension

Kyphoscoliotic heart disease

Other secondary pulmonary hypertension

Cor pulmonale (chronic)

Chronic pulmonary embolism

Other specified pulmonary heart diseases

Nonrheumatic mitral (valve) insufficiency

Nonrheumatic mitral (valve) prolapse

Nonrheumatic mitral (valve) stenosis

CMS Limitations Guide ? Cardiovascular Services

I34.8 I35.0 I35.1 I35.2 I35.8 I36.0 I36.1 I36.2 I36.8 I37.0 I37.1 I37.2 I37.8 I42.0 I42.1 I42.2 I42.3 I42.4 I42.5 I42.6 I42.7 I42.8 I42.9 I43 I44.0 I44.1 I44.39 I44.4 I44.5 I44.69 I45.0 I45.19 I45.2 I45.3

Other nonrheumatic mitral valve disorders Nonrheumatic aortic (valve) stenosis Nonrheumatic aortic (valve) insufficiency Nonrheumatic aortic (valve) stenosis with insufficiency Other nonrheumatic aortic valve disorders Nonrheumatic tricuspid (valve) stenosis Nonrheumatic tricuspid (valve) insufficiency Nonrheumatic tricuspid (valve) stenosis with insufficiency Other nonrheumatic tricuspid valve disorders Nonrheumatic pulmonary valve stenosis Nonrheumatic pulmonary valve insufficiency Nonrheumatic pulmonary valve stenosis with insufficiency Other nonrheumatic pulmonary valve disorders Dilated cardiomyopathy Obstructive hypertrophic cardiomyopathy Other hypertrophic cardiomyopathy Endomyocardial (eosinophilic) disease Endocardial fibroelastosis Other restrictive cardiomyopathy Alcoholic cardiomyopathy Cardiomyopathy due to drug and external agent Other cardiomyopathies Cardiomyopathy, unspecified Cardiomyopathy in diseases classified elsewhere Atrioventricular block, first degree Atrioventricular block, second degree Other atrioventricular block Left anterior fascicular block Left posterior fascicular block Other fascicular block Right fascicular block Other right bundle-branch block Bifascicular block Trifascicular block

CMS Limitations Guide ? Cardiovascular Services

I45.4 I45.5 I45.6 I45.81 I45.89 I46.2 I46.8 I47.0 I47.1 I47.2 I48.0 I48.1 I48.2 I48.3 I48.4 I49.01 I49.02 I49.1 I49.2 I49.3 I49.49 I49.5 I49.8 I50.1 I50.20 I50.21 I50.22 I50.23 I50.31 I50.32 I50.33 I50.41 I50.42 I50.43

Nonspecific intraventricular block Other specified heart block Pre-excitation syndrome Long QT syndrome Other specified conduction disorders Cardiac arrest due to underlying cardiac condition Cardiac arrest due to other underlying condition Re-entry ventricular arrhythmia Supraventricular tachycardia Ventricular tachycardia Paroxysmal atrial fibrillation Persistent atrial fibrillation Chronic atrial fibrillation Typical atrial flutter Atypical atrial flutter Ventricular fibrillation Ventricular flutter Atrial premature depolarization Junctional premature depolarization Ventricular premature depolarization Other premature depolarization Sick sinus syndrome Other specified cardiac arrhythmias Left ventricular failure Unspecified systolic (congestive) heart failure Acute systolic (congestive) heart failure Chronic systolic (congestive) heart failure Acute on chronic systolic (congestive) heart failure Acute diastolic (congestive) heart failure Chronic diastolic (congestive) heart failure Acute on chronic diastolic (congestive) heart failure Acute combined systolic (congestive) and diastolic (congestive) heart failure Chronic combined systolic (congestive) and diastolic (congestive) heart failure Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

CMS Limitations Guide ? Cardiovascular Services

I50.9 I51.4 I51.5 I51.7 I51.81 I63.031 I63.032 I63.131 I63.132 I65.21 I65.22 I65.23 I70.0 I70.211 I70.212 I70.213 I70.221 I70.222 I70.223 I70.231 I70.232 I70.233 I70.234 I70.235 I70.238 I70.241 I70.242 I70.243 I70.244 I70.245 I70.248 I70.25 I70.261 I70.262

Heart failure, unspecified Myocarditis, unspecified Myocardial degeneration Cardiomegaly Takotsubo syndrome Cerebral infarction due to thrombosis of right carotid artery Cerebral infarction due to thrombosis of left carotid artery Cerebral infarction due to embolism of right carotid artery Cerebral infarction due to embolism of left carotid artery Occlusion and stenosis of right carotid artery Occlusion and stenosis of left carotid artery Occlusion and stenosis of bilateral carotid arteries Atherosclerosis of aorta Atherosclerosis of native arteries of extremities with intermittent claudication, right leg Atherosclerosis of native arteries of extremities with intermittent claudication, left leg Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs Atherosclerosis of native arteries of extremities with rest pain, right leg Atherosclerosis of native arteries of extremities with rest pain, left leg Atherosclerosis of native arteries of extremities with rest pain, bilateral legs Atherosclerosis of native arteries of right leg with ulceration of thigh Atherosclerosis of native arteries of right leg with ulceration of calf Atherosclerosis of native arteries of right leg with ulceration of ankle Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot Atherosclerosis of native arteries of right leg with ulceration of other part of foot Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg Atherosclerosis of native arteries of left leg with ulceration of thigh Atherosclerosis of native arteries of left leg with ulceration of calf Atherosclerosis of native arteries of left leg with ulceration of ankle Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot Atherosclerosis of native arteries of left leg with ulceration of other part of foot Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg Atherosclerosis of native arteries of other extremities with ulceration Atherosclerosis of native arteries of extremities with gangrene, right leg Atherosclerosis of native arteries of extremities with gangrene, left leg

CMS Limitations Guide ? Cardiovascular Services

I70.263 I70.291 I70.292 I70.293 I70.311

I70.312

I70.313

I70.321 I70.322 I70.323

I70.331 I70.332 I70.333 I70.334

I70.335

I70.338

I70.341 I70.342 I70.343 I70.344

I70.345

I70.348

I70.35 I70.361 I70.362 I70.363

I70.391 I70.392 I70.393 I70.411

Atherosclerosis of native arteries of extremities with gangrene, bilateral legs

Other atherosclerosis of native arteries of extremities, right leg

Other atherosclerosis of native arteries of extremities, left leg

Other atherosclerosis of native arteries of extremities, bilateral legs

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral legs Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, bilateral legs Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of thigh

Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of calf

Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of ankle

Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of heel and midfoot Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of foot Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh

Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of calf

Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of ankle

Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of heel and midfoot Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of unspecified type of bypass graft(s) of other extremity with ulceration

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, right leg

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, left leg

Atherosclerosis of unspecified type of bypass graft(s) of the extremities with gangrene, bilateral legs Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg

Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg

Other atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs

Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudication, right leg

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