Cigna Medical Coverage Policies

Transcription

1 Cigna Medical Coverage Policies Cardiac Imaging Guidelines Effective February 21, 2014 Instructions for use The following coverage policy applies to health benefit plans administered by Cigna. Coverage policies are intended to provide guidance in interpreting certain standard Cigna benefit plans and are used by medical directors and other health care professionals in making medical necessity and other coverage determinations. Please note the terms of a customer s particular benefit plan document may differ significantly from the standard benefit plans upon which these coverage policies are based. For example, a customer s benefit plan document may contain a specific exclusion related to a topic addressed in a coverage policy. In the event of a conflict, a customer s benefit plan document always supersedes the information in the coverage policy. In the absence of federal or state coverage mandates, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of: 1. The terms of the applicable benefit plan document in effect on the date of service 2. Any applicable laws and regulations 3. Any relevant collateral source materials including coverage policies 4. The specific facts of the particular situation Coverage policies relate exclusively to the administration of health benefit plans. Coverage policies are not recommendations for treatment and should never be used as treatment guidelines. This evidence-based medical coverage policy has been developed by MedSolutions, Inc. Some information in this coverage policy may not apply to all benefit plans administered by Cigna. CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. Copyright 2014 MedSolutions, Inc.

2 CARDIAC IMAGING GUIDELINES CARDIAC Imaging Guideline Title and Number Abbreviations 3 Glossary 4 CD-1~General Guidelines 5 CD-2~Echocardiography (ECHO) 16 CD-3~Nuclear Cardiac Imaging (MPI) (MUGA) 27 CD-4~Ultrafast CT, EBCT, or Multidetector CT for Coronary Calcium Scoring 34 CD-5~Cardiac Imaging Based on Coronary Calcium Score 35 CD-6~Cardiac MRI 36 CD-7~Cardiac PET 41 CD-8~CT Heart and Coronary Computed Tomography Angiography (CCTA) 43 CD-9~Diagnostic Heart Catheterization 50 CD-10~Pulmonary Artery and Vein Imaging 57 CD-11~Syncope 58 CD-12~Congestive Heart Failure 59 CD-13~Cardiac Trauma 61 Version 16.0; Effective CARDIAC RETURN Page 2 of 61

3 ABBREVIATIONS for CARDIAC GUIDELINES ACC ACS AHA ASCOT ASD BMI CABG CAD CHF COPD CT CCTA CTA EBCT ECP ECG ECP ETT FDG HCM IV LAD LDL-C LHC LV LVEF MI MPI MRA MRI msv MUGA PCI PET PTCA RHC SPECT TEE TIA VSD American College of Cardiology acute coronary syndrome American Heart Association Anglo-Scandinavian Cardiac Outcomes Trial atrial septal defect body mass index coronary artery bypass grafting coronary artery disease congestive heart failure chronic obstructive pulmonary disease computed tomography coronary computed tomography angiography computed tomography angiography electron beam computed tomography external counterpulsation (also known as EECP) electrocardiogram external counterpulsation exercise treadmill stress test fluorodeoxyglucose hypertrophic cardiomyopathy intravenous left anterior descending coronary artery low density lipoprotein cholesterol left heart catheterization left ventricle left ventricular ejection fraction myocardial infarction myocardial perfusion imaging (SPECT study, nuclear cardiac study) magnetic resonance angiography magnetic resonance imaging millisievert (a unit of radiation exposure) multi gated acquisition scan percutaneous coronary intervention (includes percutaneous coronary angioplasty (PTCA) and coronary artery stenting) positron emission tomography percutaneous coronary angioplasty right heart catheterization single photon emission computed tomography transesophageal echocardiogram Transient Ischemic Attack ventricular septal defect Version 16.0; Effective CARDIAC RETURN Page 3 of 61

4 GLOSSARY for CARDIAC GUIDELINES Agatston Score: a calcium score for the coronary arteries; the only calcium score accepted by MedSolutions Angina: principally chest discomfort, exertional (or with emotional stress) and relieved by rest or nitroglycerine Anginal variants or equivalents: a manifestation of myocardial ischemia which is perceived by patients to be (otherwise unexplained) dyspnea, unusual fatigue, more often seen in women and may be unassociated with chest pain ARVD/ARVC Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy: a potentially lethal inherited disease with syncope and rhythm disturbances, including sudden death, as presenting manifestations BNP: B-type natriuretic peptide, blood test used to diagnose and track heart failure (n-t-pro-bnp is a variant of this test) Brugada Syndrome: an electrocardiographic pattern that is unique and might be a marker for significant life threatening dysrhythmias Double product: systolic blood pressure times heart rate, generally calculated at peak exercise; over means an adequate stress load was performed Fabry s Disease: an infiltrative cardiomyopathy, can cause heart failure and arrhythmias Hibernating myocardium: viable but poorly functioning or non-functioning myocardium which likely could benefit from intervention to improve myocardial blood supply Moderate exercise: the ability of a patient to perform the equivalent of a trot Optimized Medical Therapy should include (where tolerated): antiplatelet agents, calcium channel antagonists, partial fatty acid oxidase inhibitors (e.g. ranolazine), statins, short-acting nitrates as needed, long-acting nitrates up to 6 months after an acute coronary syndrome episode, beta blocker drugs (optional), angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blocking (ARB) agents (optional) Platypnea: shortness of breath when upright or seated (the opposite of orthopnea) and can indicate cardiac malformations, shunt or tumor Silent ischemia: cardiac ischemia discovered by testing only and not presenting as a syndrome or symptoms Syncope: loss of consciousness; near-syncope is not syncope Takotsubo cardiomyopathy: apical dyskinesis oftentimes associated with extreme stress and usually thought to be reversible Troponin: a marker for ischemic injury, primarily cardiac Volume Score: another type of calcium score under consideration for acceptance Version 16.0; Effective CARDIAC RETURN Page 4 of 61

5 CARDIAC IMAGING GUIDELINES CD-1~GENERAL GUIDELINES CD-1 GENERAL GUIDELINES 1.1 General Issues - Cardiac Stress Testing without Imaging - Procedures Stress Testing with Imaging - Procedures Stress Testing with Imaging - Indications Stress Testing with Imaging - Preoperative Transplant Patients SPECT/CT Fusion Imaging Non-imaging Heart Function and Cardiac Shunt Imaging External Counter Pulsation (ECP) Minimally Invasive or Robotic Surgery 13 Version 16.0; Effective CARDIAC RETURN Page 5 of 61

6 CD-1.1 General Issues Cardiac CARDIAC IMAGING GUIDELINES CD-1~GENERAL GUIDELINES Cardiac imaging is not indicated if the results will not affect patient management decisions. If a decision to perform cardiac catheterization or other angiography has already been made, there is often no need for imaging stress testing. A current clinical evaluation (within 60 days) is required prior to considering advanced imaging, which includes: o Relevant history and physical examination and appropriate laboratory studies and non advanced imaging modalities, such as recent EKG (within 60 days), chest x- ray or ECHO/ultrasound, after symptoms started or worsened Effort should be made to obtain copies of reported abnormal ECG studies in order to determine whether the ECG is uninterpretable Most recent previous stress testing and its findings Other meaningful contact (telephone call, electronic mail or messaging) by an established patient can substitute for a face-to-face clinical evaluation. o Vital signs, height and weight or BMI or description of general habitus is needed. o Advanced imaging should answer a clinical question which will affect management of the patient s clinical condition o Assessment of coronary artery disease can be determined by the following: Typical angina (definite): 1) Substernal chest pain or discomfort that is, 2) provoked by exertion or emotional stress and, 3) relieved by rest and/or nitroglycerin. Atypical angina (probable): Chest pain or discomfort (arm or jaw pain) that lacks one of the characteristics of definite or typical angina. Non-anginal chest pain: Chest pain or discomfort that meets one or none of the typical angina characteristics. Anginal variants or equivalents: a manifestation of myocardial ischemia which is perceived by patients to be (otherwise unexplained) dyspnea, unusual fatigue, more often seen in women and may be unassociated with chest pain See Table on Next Page Version 16.0; Effective CARDIAC RETURN Page 6 of 61

7 Table 1 Age(years) 39 and younger and over High Intermediate Low Very Low CARDIAC IMAGING GUIDELINES Pre-Test Probability of CAD by Age, Gender, and Symptoms Typical/Definite Atypical/Probable Non-anginal Gender Asymptomatic Angina Pectoris Angina Pectoris Chest Pain Men Intermediate Intermediate Low Very low Women Intermediate Very low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Low Very low Very low Men High Intermediate Intermediate Low Women Intermediate Intermediate Low Very low Men High Intermediate Intermediate Low Women High Intermediate Intermediate Low Greater than 90% pre-test probability Between 10% and 90% pre-test probability Between 5% and 10% pre-test probability Less than 5% pre-test probability CD 1.2 Stress Testing without Imaging - Procedures The Exercise Treadmill Test (ETT) is without imaging. Necessary components of an ETT include: o ECG that can be interpreted for ischemia o Patient capable of exercise on a treadmill or similar device (generally at 4 METs or greater, see functional capacity below) An abnormal ETT (exercise treadmill test) includes any one of the following: o ST segment depression o Development of chest pain o Significant arrhythmia (especially ventricular arrhythmia) o Hypotension Functional capacity greater than or equal to 4 METs equates to the following: o Can walk four blocks without stopping o Can climb two flights of stairs without stopping Version 16.0; Effective CARDIAC RETURN Page 7 of 61

8 CD-1.3 Stress Testing with Imaging- Procedures Imaging Stress Tests include any one of the following: o Stress Echocardiography [see: CD-2.6] o MPI [see CD-3.1] o Stress perfusion MRI [see: CD-6.3] Stress testing with imaging can be performed with maximal exercise or chemical stress (dipyridamole, dobutamine, adenosine or adenosine analogs) and does not alter the CPT codes used to report these studies. Version 16.0; Effective CARDIAC RETURN Page 8 of 61

9 CD-1.4 Stress Testing with Imaging - Indications STRESS TESTING with IMAGING - INDICATIONS Stress echo, MPI OR stress MRI, can be considered for the following: 1. New, recurrent or worsening cardiac symptoms AND with any of the following: o High pretest probability (greater than 90% probability of CAD) per Table 1 o A history of CAD based on A prior anatomic evaluation of the coronaries OR A history of CABG or PCI o Unheralded syncope (not near syncope) in patient with high likelihood of CAD o Evidence or high suspicion of ventricular tachycardia o Age 50 years or greater and known diabetes mellitus o Coronary calcium score >/= 400 o New or previously unrecognized uninterpretable ECG o Poorly controlled hypertension, generally, above 180 mm Hg systolic, if provider feels strongly that CAD needs evaluation prior to BP being controlled. o ECG is un-interpretable for ischemia due to any one of the following: Complete Left Bundle Branch Block (bifasicular block involving right bundle branch and left anterior hemiblock does not render ECG uninterpretable for ischemia) Ventricular paced rhythm Pre-excitation pattern such as Wolff-Parkinson-White >0.5 mm ST segment depression (NOT nonspecific ST/T wave changes) LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria) T wave inversion in the inferior and/or lateral leads. (leads II, AVF, V5, or V6) Patient on digitalis preparation o Worsening or continuing symptoms in a patient who had a normal or submaximal exercise treadmill test and there is suspicion of a false negative result. o Patients with recent equivocal, borderline, or abnormal stress testing where ischemia remains a concern o Heart rate less than 50 bpm in patients on beta blocker and/or calcium channel blocker medication where it is felt that the patient may not achieve an adequate workload for a diagnostic exercise study. o Inadequate ETT: Physical inability to perform a maximum exercise workload History of false positive exercise treadmill test: a false positive ETT is one that is abnormal however the abnormality does not appear to be due to macrovascular CAD Continued on next page... Version 16.0; Effective CARDIAC RETURN Page 9 of 61

10 CD-1.4 Stress Testing with Imaging Indications Continued... STRESS TESTING with IMAGING - INDICATIONS Stress echo, MPI OR stress MRI, can be considered for the following: 2. Asymptomatic patient with an uninterpretable ECG that never been evaluated or is new change. 3. Asymptomatic patient with an elevated cardiac troponin. 4. Routine study >2 years after a PCI (stent) without cardiac symptoms 5. Routine study >5 years after CABG without cardiac symptoms 6. Every 2 years if there was documentation of previous silent ischemia (and DM) on the imaging portion of a stress test but not on the ECG portion. 7. To assess for CAD in a patient taking flecainide or propafenone Prior anatomic imaging study (coronary angiogram or CCTA) demonstrating 8. coronary stenosis in a major coronary branch which is of uncertain functional significance can have one stress test with imaging. Within 3 months of an acute coronary syndrome (e.g. ST segment elevation MI [STEMI], unstable angina, non-st segment elevation MI [NSTEMI]), one MPI can be performed to evaluate for inducible ischemia if all of the following related to the 9. most recent acute coronary event apply: o Individual is hemodynamically stable o No recurrent chest pain symptoms and no signs of heart failure o No prior coronary angiography or imaging stress test in regards to the current episode of symptoms 10. Evaluating new, recurrent or worsening left ventricular dysfunction/chf 11. 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. o NOTE: MRI, cardiac PET, or MPI can be used to assess myocardial viability depending on physician preference Version 16.0; Effective CARDIAC RETURN Page 10 of 61

11 CD-1.5 Stress Testing with Imaging - Preoperative There are 2 steps that determine the need for imaging stress testing in (stable) preoperative patients: 1. Would the patient qualify for imaging stress testing independent of planned surgery? A. If Yes, proceed to stress testing guidelines; B. If No, go to question # 2 2. Is the surgery considered high, moderate or low risk (see Table 2) If high- or moderate-risk, proceed below. If low-risk, there is no evidence to determine a need for pre-operative cardiac testing. Table 2 Cardiac Risk Stratification List High Risk (>5%) Intermediate Risk (1-5%) Low Risk (<1%) Open aortic and other major open vascular surgery Open peripheral vascular surgery Open intraperitoneal or intrathoracic surgery Open carotid endarterectomy Head and neck surgery Open orthopedic surgery Open prostate surgery Proceed with Imaging Stress Testing if: High Risk Surgery: All patients in this category should receive stress testing Intermediate Surgery: 1 or more risk factors and unable to perform an ETT per guidelines Low Risk: Pre-operative imaging stress testing is not supported Clinical Risk Factors (for cardiac death and non-fatal MI at the time of non-cardiac surgery) 1. Planned high risk surgery (open surgery on the aorta or open peripheral vascular surgery) 2. History of ischemic heart disease (previous MI, previous positive stress test, use of nitroglycerin, typical angina, ECG Q waves, previous PCI or CABG) 3. History of compensated previous congestive heart failure (history of heart failure, previous pulmonary edema, third heart sound, bilateral rales, chest x-ray showing heart failure) 4. History of previous TIA or stroke 5. Diabetes Mellitus 6. Creatinine level >2 mg/dl Endoscopic procedures Superficial procedures Cataract surgery Breast surgery Ambulatory surgery Laparoscopic procedures and endovascular procedures that are unlikely to require further extensive surgical intervention Version 16.0; Effective CARDIAC RETURN Page 11 of 61

12 CD-1.6 Transplant Patients Stress Testing in Transplant Patients Individuals who are candidates for any type of organ bone marrow or stem cell transplant can undergo imaging stress testing every year (usually stress echo or MPI) prior to transplant. Individuals who have undergone organ transplant are at increased risk for ischemic heart disease secondary to their medication. Risk of vasculopathy is 7% at one year, 32% at five years and 53% at ten years. An imaging stress test can be repeated annually after transplant for at least two years or within one year of a prior cardiac imaging study if there is evidence of progressive vasculopathy. After two consecutive normal imaging stress tests, repeated testing is not supported more often than every other year without evidence for progressive vasculopathy or new symptoms. Stress testing after five years may proceed according to normal patterns of consideration. There is insufficient evidence to support routine use of Coronary Computed Tomography Angiography (CCTA) in the evaluation of the coronary arteries following heart transplantation. CD-1.7 SPECT/CT Fusion Imaging There is currently no evidence-based data to formulate appropriateness criteria for SPECT/CT fusion scans. Combined use of nuclear imaging, including SPECT, along with diagnostic CT (fused SPECT/CT) is considered investigational CD-1.8 Non-imaging Heart Function and Cardiac Shunt Imaging Procedures reported with CPT and CPT are essentially obsolete and should not be performed in lieu of other preferred modalities. Echocardiogram is the preferred method for cardiac shunt detection rather than the cardiac shunt imaging study described by CPT Ejection fraction can be obtained by echocardiogram, MPI, MUGA study, cardiac MRI, cardiac CT, or cardiac PET depending on the clinical situation, rather than by the non-imaging heart function study described by CPT Version 16.0; Effective CARDIAC RETURN Page 12 of 61

13 CD-1.9 External Counter Pulsation (ECP) ECP (sometimes referred to as Enhanced External Counterpulsation or EECP ) is a therapy aimed at stimulating the formation of collateral circulation to the myocardium in patients with chronic stable angina who are not candidates for invasive methods of revascularization such as coronary bypass surgery or angioplasty/stenting. A course of ECP generally consists of 35 sessions (1 to 2 hour sessions, five days a week for 7 weeks). Since the therapeutic benefit of ECP is enhanced at six months and sustained at 24 months post treatment, a repeat course of ECP earlier than 1 to 2 years from the last course of ECP is generally not indicated. The usual procedure code for ECP is G0166, which is an all-inclusive code o External cardiac assistance (CPT 92971), ECG rhythm strip and report (CPT or CPT 93041), pulse oximetry (CPT or CPT 94761), and plethysmography (CPT or CPT 93923) should not be separately requested or billed with G0166. o MedSolutions does not, currently, prior authorize procedure code G0166. CD-1.10 Minimally Invasive or Robotic Surgery There is insufficient data to support the routine use of CTA for the routine evaluation of peripheral arteries, iliac arteries, and/or aorta prior to minimally invasive or robotic surgery. Transcatheter Aortic Valve Replacement (TAVR): o CTA of chest, abdomen and pelvis (CPT 71275, CPT 74175, and CPT 72191) is considered appropriate, and o Cardiac CT (CPT 75572) may be considered to measure the aortic annulus (2) or o Coronary CTA (CCTA CPT 75574) may be considered to both measure the aortic annulus and assess the coronary arteries in lieu of heart catheterization. Version 16.0; Effective CARDIAC RETURN Page 13 of 61

14 References 1. Adabag AS, Grandits GA, Prineas RJ, et al. Relation of heart rate parameters during exercise test to sudden death and all-cause mortality in asymptomatic men. Am J Cardiol 2008;101: Brindis RG, Douglas PS, Hendel RC, et al. ACCF/ASNC Appropriateness Criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI). J Am Coll Cardiol 2005;46(8): Cardiac stress test supplement. Institute for Clinical Systems Improvement. February 20, 2007, Accessed October 23, Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2007;50(17): Freeman WK and Gibbons RJ. Perioperative cardiovascular assessment of patients undergoing noncardiac surgery. Mayo Clin Proc 2009 Jan;84(1): Friedewald VE, King SB, Pepine CJ, et.al. The Editor s Roundtable: Chronic stable angina pectoris. Am J Cardiol 2007 Dec;100(11): Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 Guideline Update for Exercise Testing Summary Article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002; 40: Ho PM, Rumsfeld JS, Peterson PN. Chest pain on exercise treadmill test predicts future cardiac hospitalizations. Clin Cardiol 2007;30: Lauer MS, Pothier CE, Magid DJ, et al. An externally validated model for predicting long-term survival after exercise treadmill testing in patients with suspected coronary artery disease and a normal electrocardiogram. Ann Intern Med 2007;147: Marshall AJ, Hutchings F, James AJ, et al. Prognostic value of a nine minute treadmill test in patients undergoing myocardial perfusion scintigraphy. Am J Cardiol 2010 Nov: 106(10): Michaels AD, Linnemeier G, Soran O, et al. Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]). Am J Cardiol 2004 Feb 15;93(4): Mieres JH and Blumenthal RS. Does the treadmill test work in women? Cardiosource Spotlight July 1, 2008;CS2-CS4 13. Peterson PN, Magid DJ, Ross C, et al. Association of exercise capacity on treadmill with future cardiac events in patients referred for exercise testing. Arch Intern Med 2008;168(2): Picano E, Pasanisi E, Brown J, et al. A gatekeeper for the gatekeeper: Inappropriate referrals to stress echocardiography. Am Heart J 2007;154: Poirier P, Alpert MA, Fleisher LA, et al. Cardiovascular evaluation and management of severely obese patients undergoing surgery: a science advisory from the American Heart Association. Circulation 2009;120: Sechtem U. Do heart transplant recipients need annual coronary angiography? Eur Heart J 1997; Southard J, Baker L, Schaefer S. In search of the false-negative exercise treadmill testing evidencebased use of exercise echocardiography. Clin Cardiol 2008;31: Tavel ME. Stress testing in cardiac evaluation: Current concepts with emphasis on the ECG. Chest 2001;119: Taylor DO, Edwards LB, Boucek MM, et al. Registry of the International Society for Heart and Lung Transplantation: Twenty-fourth official adult heart transplant report J Heart Lung Version 16.0; Effective CARDIAC RETURN Page 14 of 61

15 Transplant 2007 August;26(8): Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol 2002;40: Diamond GA. A clinically relevant classification of chest discomfort. J Am Coll Cardiol 1983;1: Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, Min JK, Patel MR, Rosenbaum L, Shaw LJ, Stainback RF, Allen JM. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS Multi-modality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation, Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 63: forthcoming. 23. Blank P, Scheopf UJ, Leipsic JA. CT in transcatheter aortic valve replacment. Radiology, 2013; 269: (2) ACR Appropriateness Criteria Imaging for Transcatheter Aortic Valve Replacement, Journal of the American College of Radiology, Volume 10, Issue 12, Pages , December 2013 Version 16.0; Effective CARDIAC RETURN Page 15 of 61

16 CARDIAC IMAGING GUIDELINES CD-2~Echocardiography (ECHO) CD-2 Echocardiography 2.1 Transthoracic Echocardiography (TTE) - Coding Transthoracic Echocardiography (TTE) - Indications Frequency of Echocardiography Testing Transesophageal Echocardiography (TEE) - Coding Transesophageal Echocardiography (TEE) - Indications Stress Echocardiography (Stress Echo) - Coding Stress Echocardiography (Stress Echo) - Indications D Echocardiography - Coding D Echocardiography - Indications 26 Version 16.0; Effective CARDIAC RETURN Page 16 of 61

17 CARDIAC IMAGING GUIDELINES CD-2~Echocardiography (ECHO) CD-2.1 Transthoracic Echocardiography (TTE) - Coding TTE CODES Transthoracic Echocardiography CPT TTE for congenital cardiac anomalies, complete TTE for congenital cardiac anomalies, follow-up or limited TTE with 2-D, M-mode, Doppler and color flow, complete TTE with 2-D, M-mode, without Doppler or color flow TTE with 2-D, M-mode, follow-up or limited Doppler Echocardiography CPT Doppler echo, pulsed wave and/or spectral display * Doppler echo, pulsed wave and/or spectral display, follow-up or limited study * Doppler echo, color flow velocity mapping *CPT and CPT should not be requested or billed together The most commonly performed study is a complete transthoracic echocardiogram with spectral and color flow Doppler (CPT 93306). o CPT includes the Doppler exams, so CPT codes should not be assigned together with CPT o Doppler codes (CPT 93320, CPT 93321, and CPT 93325) are add-on codes (as denoted by the + sign) and are assigned in addition to code for the primary procedure. For a 2D transthoracic echocardiogram without Doppler, report CPT Limited transthoracic echocardiogram should be billed if the report does not evaluate or document the attempt to evaluate all of the required structures. o A limited transthoracic echocardiogram is reported with CPT o CPT (not CPT 93320) should be reported with CPT if Doppler is included in the study. CPT can be reported with CPT if color flow Doppler is included in the study. o A limited congenital transthoracic echocardiogram is reported with CPT Doppler echo may be used for evaluation of the following: o Shortness of breath o Known or suspected valvular disease o Known or suspected hypertrophic obstructive cardiomyopathy shunt detection o NOTE: Providers performing echo on a pediatric patient, may not know what procedure codes they will be reporting until the initial study is completed. Version 16.0; Effective CARDIAC RETURN Page 17 of 61

18 If a congenital issue is found on the initial echo, a complete echo is reported with codes CPT 93303, CPT 93320, and CPT because CPT does NOT include Doppler and color flow mapping. If no congenital issue is discovered, then CPT is reported alone and includes 2-D, Doppler and color flow mapping. Since providers may not know the appropriate code/s that will be reported at the time of the pre-authorization request, they may request all 4 codes (CPT 93303, CPT 93320, CPT 93325, and CPT 93306). Depending upon individual health plan payor contracts, post-service audits may be completed to ensure proper claims submission. Please Note: CPT and CPT are not unique to 3D Echo. These codes also apply to 3D rendering of MRI and CT studies.. Version 16.0; Effective CARDIAC RETURN Page 18 of 61

19 CD-2.2 Transthoracic Echocardiography (TTE) - Indications TTE can be performed for the following: Valve function and structure: o Valvular stenosis or regurgitation o Valvular structure o If valve surgery is being considered can have TTE twice a year Ventricular function including global and segmental wall motion for evaluating ejection fraction (EF) and coronary artery disease. o Dyspnea o Symptoms of Heart Failure o Cardiomyopathy o Chemotherapy (see: CD-3.6 MUGA Study Oncologic Indications) o Arrhythmias Ventricular structure including but not limited to: o Infiltrative diseases (e.g. sarcoid, amyloid) o Aneurysm with/without thrombus o Ventricular septal defect (VSD) o Papillary muscle rupture/dysfunction o Hypertrophy (including asymmetric septal hypertrophy, spade heart, hypertensive concentric hypertrophy, infiltrative hypertrophy) Evaluation of right ventricular systolic pressure/pulmonary hypertension Evaluation of atrial or ventricular chamber size (e.g. patients with atrial fibrillation, tachyarrhythmias, or left ventricular dilatation) o Yearly TTE may be indicated depending on the clinical circumstance. Cardiac Defects or Masses o Embolic source in patients with recent Transient Ischemic Attack (TIA), stroke, or peripheral vascular emboli as an initial study before TEE. o ASD repair or VSD repair: within the first year of surgery or if become newly symptomatic o Tumor evaluation including myxomas o Clot detection o Evaluation of congenital heart disease Continued on next page... Version 16.0; Effective CARDIAC RETURN Page 19 of 61

20 CD-2.2 Transthoracic Echocardiography (TTE) Indications Continued TTE can be performed for the following: Inflammatory o Pericardial effusion/pericardial disease including pericardial cysts o Congenital heart disease o Endocarditis (including fever, positive blood cultures indicating bacteremia, or a new murmur) 7. Pacemaker insertion complication 8. Screening for first-degree relatives of patients with hypertrophic cardiomyopathy (HCM) o First-degree relatives who are 12 to 18 years old should be screened yearly for HCM by 2D- echocardiography and ECG. o First-degree relatives who are older than age 18 should have 2D-echo and ECG every five years to screen for delayed adult-onset LVH. o Systematic screening is usually not indicated for first-degree relatives who are younger than age 12 unless there is a high-risk family history or the child is involved in particularly intense competitive sports. o Affected individuals identified through family screening or otherwise should be evaluated every 12 to18 months with 2D-echo, Holter monitor, and blood pressure response during maximal upright exercise. Version 16.0; Effective CARDIAC RETURN Page 20 of 61

21 CD-2.3 Frequency of Echocardiography Testing Frequency of Echocardiography Testing Repeat routine echocardiograms are not supported (annually or otherwise) for evaluation of clinically stable syndromes, including valvular heart disease, evaluation of prosthetic valve, cardiomyopathy, or hypertension. Once a year, when there is evidence for change in (1) clinical status or (2) to assess new or changing interventions (medical or surgical): o Left ventricular hypertrophy progression or regression o Significant valve dysfunction o Cardiac chamber size in cardiomyopathy and atrial dysrhythmias o Chronic pericardial effusions o Left ventricular contractility/diastolic function prior to planned medical therapy for heart failure or to evaluate the effectiveness of on-going therapy o Aortic root dilatation Twice a year for the following assessments: o New or changing (not chronic stable) pericardial effusions o New/changed medical therapy for congestive heart failure o New/changed medical therapy for hypertension if left ventricular hypertrophy was present o Hypertrophic cardiomyopathy when the results of the echo will potentially change patient management o Critical valvular heart disease when the results of the echo will potentially change patient management Anytime without regard for the number of previous ECHO studies based on new acute, worsening or suspicion of: o Cardiac murmurs o Myocardial infarction or acute coronary syndrome o Congestive heart failure (or new symptoms of dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, elevated BNP) o Pericardial disease o Stroke/transient ischemic attack o Decompression illness o Prosthetic valve dysfunction or thrombosis Version 16.0; Effective CARDIAC RETURN Page 21 of 61

22 CD 2.4: Transesophageal Echocardiography (TEE) - Coding TEE PROCEDURE CODES Transesophageal Echocardiography CPT TEE with 2-D, M-mode, probe placement, image acquisition, interpretation and report TEE probe placement only TEE image acquisition, interpretation, and report only TEE for congenital anomalies with 2-D, M-mode, probe placement, image acquisition, interpretation and report TEE for congenital anomalies, probe placement only TEE for congenital anomalies, image acquisition, interpretation and report only TEE for monitoring purposes, ongoing assessment of cardiac pumping function on an immediate time basis Doppler Echocardiography*: CPT Doppler echo, pulsed wave and/or spectral display Doppler echo, pulsed wave and/or spectral display, follow-up or limited study Doppler echo, color flow velocity mapping *Doppler echo, if performed, may be reported separately in addition to the primary TEE codes: CPT 93312, CPT 93314, CPT 93315, and CPT The complete transesophageal echocardiogram service, including both (1) probe (transducer) placement and (2) image acquisition/interpretation, is reported with CPT o Probe placement only is reported with CPT o The image acquisition/interpretation only is reported with CPT Physicians assign codes CPT 93312, CPT 93313, and/or CPT to report professional services if the test is performed in a hospital or other facility where the physician cannot bill globally. o Modifier -26 (professional component) is appended to the appropriate code o CPT and CPT should never be used together. If both services are provided, CPT is reported. Hospitals should report TEE procedures using CPT (the complete service). CPT and CPT are not used for hospital billing. Monitoring of patients undergoing cardiac surgery is CPT Version 16.0; Effective CARDIAC RETURN Page 22 of 61

23 CD-2.5 Transesophageal Echocardiography (TEE) TEE INDICATIONS: 1. Limited transthoracic echo window Assessing valvular dysfunction, especially mitral regurgitation, when TTE is inadequate. Embolic source or intracardiac shunting when TTE is inconclusive o Examples: atrial septal defect, ventricular septal defect, patent foramen ovale, aortic cholesterol plaques, thrombus in cardiac chambers, valve vegetations, tumor Embolic events when there is an abnormal TTE, abnormal ECG, and a history of atrial fibrillation o Clarify atria/atrial appendage, aorta, mitral/aortic valve beyond the information that other imaging studies have provided o Cardiac valve dysfunction Differentiation of tricuspid from bicuspid aortic valve Congenital abnormalities 5. Assessing for left atrial thrombus prior to cardioversion of atrial fibrillation. 6. Repeat TEE studies are based upon findings in the original study and documentation of the way in which repeat studies will affect patient management Version 16.0; Effective CARDIAC RETURN Page 23 of 61

24 CD-2.6 Stress Echocardiography (Stress Echo) - Coding Stress ECHO Procedure Codes Stress Echocardiography CPT Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report;* Echo, transthoracic, with (2D), includes M-mode, during rest and exercise stress test and/or pharmacologically induced stress, with report: including performance of continuous electrocardiographic monitoring, with physician supervision* Doppler Echocardiography: CPT Doppler echo, pulsed wave and/or spectral display** Doppler echo, pulsed wave and/or spectral display, follow-up/limited study Doppler echo, color flow velocity mapping** *CPT and CPT do not include Doppler studies *Doppler echo (CPT and CPT ), if performed, may be reported separately in addition to the primary SE codes: CPT or CPT In general, stress echo (SE) and nuclear myocardial perfusion imaging (MPI) are considered equivalent diagnostic tests. However, in addition to myocardial ischemia, SE by its nature can provide additional information that is not obtainable with MPI such as valve function, assessment of pulmonary pressure, and assessment of dynamic obstruction. Doppler echo with a stress echo may be used for evaluation of the following: o Shortness of breath o Known or suspected valvular disease o Known or suspected hypertrophic obstructive cardiomyopathy such as idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy o Assessment of pulmonary pressures Version 16.0; Effective CARDIAC RETURN Page 24 of 61

25 CD-2.7 Stress Echocardiography (Stress Echo) - Indications See: CD-1.4 Stress Testing with Imaging Indications Medsolutions guidelines favor stress echo as the initial imaging modality for the evaluation of coronary artery disease/ischemic heart disease when stress testing with imaging is indicated (e.g. ECG is not interpretable and/or patient is unable to perform exercise). o Stress echo is favored for several reasons including: the ease of performing the test the shorter duration of testing no IV, unless contrast is used no radiation exposure. Presently, MedSolutions does NOT require a Stress Echo be completed as the initial evaluation in these patients. (See: CD-1.4 for complete indications for stress testing with imaging) Advantages of stress echo over nuclear cardiac (MPI) stress test 1 include: o Lack of ionizing radiation o Shorter imaging times o Portability o Immediate availability of results o Availability of ancillary information about chamber sizes and function, valves, pericardial effusion, aortic root disease, wall thickness Stress ECHO Indications In addition to the evaluation of CAD, stress echo can effectively be used in the following conditions: o Dyspnea on exertion (specifically to evaluate pulmonary hypertension) o Right heart dysfunction o Heart murmur with no known severe valvular disease o Valvular heart disease o Exercise-induced pulmonary hypertension o Cardiomyopathies, including hypertrophic cardiomyopathy Version 16.0; Effective CARDIAC RETURN Page 25 of 61

26 CD-2.8 3D Echocardiography - Coding The procedure codes used to report 3D rendering for echocardiography are the same codes used to report the 3D post processing work for CT, MRI, ultrasound and other tomographic modalities. o CPT 76376, not requiring image post-processing on an independent workstation, is the most common code used for 3D rendering done with echocardiography o CPT requires the use of an independent workstation o In addition to the clinical indications, proper reporting of the codes requires concurrent supervision of image post-processing 3D manipulation of volumetric data set and image rendering. CD-2.9 3D Echocardiography - Indications 3D Echo Indications Echocardiography with 3-dimensional (3D) rendering is becoming universally available, yet its utility remains limited based on the current literature. Current indications include: o Left ventricular volume and ejection fraction assessment o Mitral valve anatomy specifically related to mitral valve stenosis o Guidance of transcatheter procedures References 1. Bangalore S, Yao SS, Chaudhry FA. Usefulness of stress echocardiography for risk stratification and prognosis of patients with left ventricular hypertrophy. Am J Cardiol 2007;100: CPT Changes 2013: An Insider s View, page Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 Appropriateness Criteria for Stress Echocardiography. J Am Coll Cardiol 2008;51: Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology Clinical Expert Consensus Document on Hypertrophic Cardiomyopathy. European Heart Journal 2003;24: Metz LD, Beattie M, Hom R, et al. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: A meta-analysis. J Am Coll Cardiol 2007;49(2): Pellikka PA, Nagueh SF, Elhendy AA, et al. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. Journal of the American Society of Echocardiography 2007;20(9): Tandogan I, Yetkin E, Yanik A, et al. Comparison of thallium-201 exercise SPECT and dobutamine stress echocardiography for diagnosis of coronary artery disease in patients with left bundle branch block. International Journal of Cardiovascular Imaging 2001;17: Version 16.0; Effective CARDIAC RETURN Page 26 of 61

27 CARDIAC IMAGING GUIDELINES CD-3~Nuclear Cardiac Imaging (MPI) (MUGA) CD-3 Nuclear Cardiac Imaging (MPI) (MUGA) 3.1 MPI - Coding MPI Indications (See: CD-1.4 Stress Testing with Imaging-Indications) MPI Average Estimated Radiation Dose MUGA - Coding MUGA Study Cardiac Indications MUGA Study Oncologic Indications Myocardial Sympathetic Innervation Imaging 33 Version 16.0; Effective CARDIAC RETURN Page 27 of 61

28 CD-3.1 MPI - Coding Nuclear Cardiac Imaging Procedure Codes Myocardial Perfusion Imaging (MPI) CPT MPI, 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) MPI, 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 redistribution and/or rest reinjection The most commonly performed myocardial perfusion imaging are single (at rest or stress, CPT 78451) and multiple (at rest and stress, CPT 78452) tomographic SPECT studies. o Evaluation of the individual s left ventricular wall motion and ejection fraction are routinely performed during MPI and are included in the code s definition. o First pass studies, (CPT and CPT 78483), MUGA, (CPT and CPT 78473) and SPECT MUGA (CPT 78494) should not be reported in conjunction with MPI codes. o Attenuation correction, when performed, is included in the MPI service by code definition. No additional code should be assigned for the billing of attenuation correction. Multi-day Studies: In the absence of written payor guidelines to the contrary, it is not appropriate to bill separately for the rest and stress segments of MPI even if performed on separate calendar dates. A single code is assigned to define the entire procedure on the date all portions of the study are completed. 3D rendering, (CPT 76376/CPT 76377), should not be billed in conjunction with MPI. Separate codes for such related services as treadmill testing (CPT CPT 93018) and radiopharmaceuticals should be assigned in addition to MPI. These services are paid according to each individual payor. CD-3.2 MPI Indications o (See: CD-1.4 Stress Testing with Imaging-Indications) Version 16.0; Effective CARDIAC RETURN Page 28 of 61

29 CD-3.3 MPI Average Estimated Radiation Dose Imaging Study Sestamibi myocardial perfusion study (MPI) Thallium myocardial perfusion study (MPI) Diagnostic conventional coronary angiogram (cath) Computed tomography coronary angiography (CTCA) CT of Abdomen and pelvis Chest x-ray Radiation Dose 9-12 msv 25 msv 5-10 msv 5-15 msv 8-14 msv <0.1 msv Version 16.0; Effective CARDIAC RETURN Page 29 of 61

30 CD-3.4 MUGA - Coding Nuclear Cardiac Imaging Procedure Codes MUGA (Multi Gated Acquisition) Blood Pool Imaging CPT Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress, wall motion study plus ejection fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction, at rest and stress, with or without additional quantification Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure) [Use in conjunction with CPT 78472] The technique employed for a MUGA service guides the code assignment. CPT is used for a planar MUGA scan at rest or stress, and CPT for planar MUGA scans, multiple studies at rest and stress. The two most commonly performed MUGA scans are the studies defined by CPT and SPECT MUGA, CPT Planar MUGA studies (CPT and CPT 78473) should not be reported in conjunction with: o MPI (CPT CPT 78454) o First pass studies (CPT CPT 78483), and/or o SPECT MUGA (78494). CPT is assigned only in conjunction with CPT See: CD-3.5 MUGA Study Cardiac Indications. This add-on code should not be performed and assigned as a routine protocol. Version 16.0; Effective CARDIAC RETURN Page 30 of 61

31 CD-3.5 MUGA Study Cardiac Indications NOTE: Indications below refer to scenarios in which MUGA is being performed rather than ECHO. MUGA (Multi Gated Acquisition) Blood Pool Imaging Indications 1. Prior ECHO demonstrates impaired systolic function (EF<50%). 2. Pre-existing left ventricular wall motion abnormalities from ischemic heart disease or ischemic or non-ischemic cardiomyopathies 3. Echo is technically limited and prevents accurate assessment of LV function AICD placement: MUGA to determine eligibility for ICD placement, biventricular pacing, or heart transplant if ECHO, catheterization, and/or MPI give conflicting results Congestive heart failure o MUGA to measure response to cardiac medications for CHF if there is a documented clinical need for a quantitative measurement of left ventricular ejection fraction (LVEF) beyond what echocardiography can provide. Previous low LV ejection fraction determination was o < 50% and receiving potentially cardiotoxic chemotherapy o Consideration for CRID Documentation of other need for information given by MUGA that cannot be obtained by ECHO MUGA is NOT indicated for the following: A prior MUGA is not a reason to approve another MUGA (it is not necessary to compare LVEF by the same modality) To resolve differences in ejection fraction measurements between ECHO and MPI unless there is clear documentation as to how quantitative measurement of LVEF will affect patient management (e.g. implantation of an AICD). NOTE: LV ejection fraction measurement is variable and can vary by +/-5-10% without any accompanying change in clinical status. Normal physiologic changes in intravascular volume, catecholamine levels, fever, and medications are among the many factors which cause variation in LVEF in the absence of myocardial pathology. Right ventricular first pass study, (CPT ), may be indicated if there is clear documentation of a concern regarding right ventricular dysfunction or overload. Version 16.0; Effective CARDIAC RETURN Page 31 of 61