Local Coverage Determination (LCD) for Echocardiography, Transthoracic and Transesophageal (L28254)

Centers for Medicare & Medicaid Services Print Message: If you are experiencing issues printing this page, then please click Return to Previous Page and select the 'Need a PDF?' button. You can now print the page from the new popup window. Back to Local Coverage Determinations (LCDs) for Palmetto GBA (01192, MAC - Part B) Local Coverage Determination (LCD) for Echocardiography, Transthoracic and Transesophageal (L28254) Contractor Information Contractor Name Palmetto GBA Contractor Number 01192 Contractor Type MAC - Part B LCD Information Document Information LCD ID Number L28254 LCD Title Echocardiography, Transthoracic and Transesophageal Contractor's Determination Number J1B-08-0026-L AMA CPT/ADA CDT Copyright Statement CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Primary Geographic Jurisdiction California - Southern Oversight Region Region X Original Determination Effective Date For services performed on or after 09/02/2008 Original Determination Ending Date Revision Effective Date For services performed on or after 06/14/2012 Revision Ending Date

Dental Association. CMS National Coverage Policy Title XVIII of the Social Security Act (SSA), 1862(a)(7), excludes routine physical examinations from Medicare coverage. Title XVIII of the Social Security Act, 1862(a)(1)(A), allows coverage and payment for only those services considered medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Manual System, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 220.5, Ultrasound Procedures. Transesophageal cardiac output monitoring can be covered, when medically necessary, in certain ICU and surgical patients, effective 5/17/2007. See also CR 5608. CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.4, describes billing for contrast material for use in echocardiography. CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, 60, 60.1, 60.2 and 80, indicate that the technical component of diagnostic tests is not covered as "incident-to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database. CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 10, Enrollment, 5, Independent Diagnostic Testing Facilities, indicates that non-physician owned facilities performing primarily diagnostic tests should be enrolled as IDTFs rather than billing under physician PINs. See also 42 CFR 410.33. 42 CFR 410.32 and 410.33 indicate that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment. Medicare Carrier s Manual (MCM), Section 15047, Preoperative Services Paid Under the Physician Fee Schedule (CMS Change Requests 1511 and 1815) explains that a test performed for a preoperative evaluation is a benefit of Medicare. Payment is allowed when the test is reasonable and necessary. (CMS has stated this will be crosswalked to Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, 30.6.6.1. HCFA Ruling 95-1 states that community standards of care are always binding on providers; see also 42 CFR 406.11. CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3, Diagnosis Code Requirement. Indications and Limitations of Coverage and/or Medical Necessity

Overview Echocardiography is a diagnostic test involving ultrasonic examination of the heart and its surrounding structures. Echocardiography may be clinically required to determine cardiac anatomy and measure function. Sound waves are projected toward the organ or area under examination, and characteristic reflections allow the visualization of structure and function. Doppler examination may be required as an additional part of testing. Doppler examinations determine normal or abnormal blood flow based on transmissions from moving surfaces (e.g. heart valves, red blood cells.) Doppler examinations may help characterize valvular stenosis, valvular regurgitation, cardiac output, intracardiac pressures or intracardiac shunts. Diagnostic tests are reasonable and necessary only when ordered by the treating (or consulting) physician and when results will be used for determining the diagnosis or treatment of disease. In addition, testing must be appropriate in duration and frequency, furnished in accordance with accepted standards of medical practice, furnished by qualified personnel, and reflect a service which meets, but does not exceed, the patient s need Indications Echocardiography is indicated in the evaluation of derangements of valvular, myocardial, pericardial and thoracic aortic anatomy and function. Major applications for coverage fall into the following clinical settings. These clinical conditions are covered for transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) when TTE or TEE diagnostic testing directly contributes to the management or diagnosis of disease. 1. Disease of Native Cardiac Valves Detection of mitral stenosis was among the first practical clinical applications of TTE. 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 valvular pathologies can be quantified. Visualization of the valve and valvular apparatus provides information to facilitate therapeutic decision making when competing therapeutic options exist and TTE is likely to resolve these alternatives. Serial evaluations may be clinically appropriate, for example, in the monitoring of chronic aortic pathology when images suitable for serial quantitation are required for care management decisions. 2. Prosthetic Heart Valves TTE assessment soon after prosthetic valve surgery is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Features evaluated include valvular position and function, underlying ventricular function and concomitant valvular pathologies, if any. TEE is indicated when prosthetic dysfunction is suspected or therapeutic decisions are pivotal and data is inconclusive. However, TEE is not routinely indicated in all patients with prosthetic valves. 3. Acute Endocarditis Echocardiography provides diagnostic information pertaining to valvular pathology, vegetative masses and ventricular function. Larger vegetations may be visualized with

TTE, and TTE is generally better able to define the consequences of the infective valvular process on ventricular function. TEE on the other hand, may better define smaller vegetative masses and more completely delineate local complications such as ring abscesses, aneurysms, or fistulae. In most cases TEE is not indicated as the initial evaluation in the diagnosis of native valvular endocarditis. If TTE visualization is insufficient due to body habitus (obesity, increased thoracic diameter due to chronic obstructive pulmonary disease, other anatomical characteristics) then TEE would be indicated to provide a clear initial diagnostic test for acute endocarditis. Examination frequency in the acute phase of illness is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE (or TEE) evaluation will be determined by the residual pathophysiology and discrete clinical events. 4. Ventricular Function and Cardiomyopathies Changes in myocardial thickness (hypertrophy and thinning), chamber volume, size and morphology as well as derived parameters of contractility can be quantified and charted over time by TTE. Therapeutic interventions can be assessed by repeat evaluation. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. There is increasing data to support the prognostic value of diastolic function parameters in patients with systolic dysfunction. TTE is only one method for evaluating ventricular function. Alternative methods include left ventricular angiography, gated blood pool scans and certain CT and MRI procedures. TTE and gated blood pool scans are the least costly methods of obtaining this information. Gated blood pool scans are more quantitative while TTE yields better information about wall thickness and valve function. In most cases, only one method of assessment is needed and this should be the most cost-effective method to answer the clinical question. Care should meet, but not exceed, the patient s need. In general, TTE provides accurate and serial non-invasive assessment of global and regional left ventricular function. TTE assessment of left ventricular function is considered preferable to TEE. For stable patients absent documented deterioration, repeated examinations more frequently than annually are not medically necessary. 5. Acute Myocardial Infarction and Coronary Insufficiency Echocardiography is covered for the evaluation of patients with symptoms of acute myocardial infarction when the standard battery of tests is inconclusive or when clinical decision making would be significantly affected by immediate assessment of myocardial and/or valvular function. TTE may detect depressed myocardial contractility or complications of acute myocardial infarction such as mural thrombi, papillary muscle dysfunction and/or rupture, septal defects, true or false aneurysms, and myocardial rupture. Repeat echocardiography assessment may be repeated as early as six weeks following myocardial infarction. Thereafter, repeat echocardiography, in the absence of clinical changes, requires additional justification. TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations 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. The role for TTE in the emergency room assessment of individuals who present with chest pain is in evolution. This application may be used as part of a thoughtful clinical evaluation, and in making a triage decision on a patient with chest pain syndrome. 6. Hypertensive Cardiovascular Disease TEE may be indicated in individuals with hypertension who have clinical evidence of heart disease. Left ventricular hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. TTE can be used to monitor changes in the left ventricle that might indicate the need for or beneficial results of long-term antihypertensive therapy. In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined in part by the presence of left ventricular hypertrophy and /or left ventricular mass calculation. 7. Cardiac Transplant and Rejection Monitoring TTE is an integral part of the cardiac donor selection and recipient matching process. Evaluations focus on analysis of ventricular function and the integrity of cardiac valves. Intraoperative TEE is appropriate in heart-lung transplants where the integrity and morphology of the pulmonary vascular anastomoses are critical. TTE is also used in the management of allograft recipients. TTE will determine myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics and the late development of pericardial fluid which may be signs of a rejection episode. TTE may be required weekly for the first four to eight weeks following transplant with decreasing frequency thereafter. Three TTE examinations are typically performed yearly in chronic transplant recipients in the absence of clinical deterioration or evidence of rejection. 8. 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. When echocardiography is used to monitor cardiac toxicity of chemotherapeutic agents, an initial complete TTE may be performed prior to the first administration of the agent with the frequency of repeat studies determined by the patient s clinical course and the toxicity profile of the agent being administered. 9. Pericardial Disease Detection and quantification of pericardial effusion is an important application of TTE. Small pericardial fluid accumulations (20 ml) have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. Certain TTE findings have been found to be reliable indices of cardiac tamponade. TTE facilitates removal

of pericardial fluid and the creation of pericardial windows. The acute clinical status will dictate examination frequency. TTE and doppler techniques are quite helpful in identifying pericardial constriction and differentiating it from restrictive myocardial disease. 10. Congenital Heart Disease In children and young adults, TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with doppler hemodynamic measurements, TTE usually provides accurate diagnosis and noninvasive serial assessment. 11. Cardiac Tumors and Masses TTE may assess infiltrative and ventricular tumors and masses, right atrial masses, and their hemodynamic consequences. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, attachments, etc.). These pathologies are not typically followed serially. 12. Critically Ill and Trauma Patients There is a role for echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspected aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the patient s clinical status and decision-making requirements. 13. Suspected Cardiac Thrombi and Embolic Sources TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial appendages 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 such as atrial fibrillation, cardiomyopathies and ventricular dysfunction) TTE usually provides adequate supplemental therapeutic decisional data. In those instances where the precise diagnosis and localization of potentially embolic material is of paramount therapeutic importance and the information so obtained will potentially and substantively alter therapy, or the risk of anticoagulants is inordinately high, consideration should be given to TEE if TTE provides inadequate information for clinical decisions. 14. Contrast Echocardiography Contrast TTE is indicated when a conventional study has failed to provide adequate and critically needed information on left ventricular function. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders in a patient whose non-contrast study is inadequate or suboptimal, and for whom the LV function information is essential to the management of the patient. 15. Chronic Ischemic Heart Disease TTE may be used at rest (and with exercise) in persons with chronic ischemic heart

disease for diagnosis, risk stratification, and medical management decision making. At rest, TTE is useful in demonstrating left ventricular function and wall motion as well as valvular and papillary muscle function that are often abnormal in ischemic states. For this A/B MAC's Local Coverage Determination on Stress Echocardiography, please see www.palmettogba.com/j1, Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography. 16. Aortic Pathology TTE can provide valuable information when acute or chronic aortic pathology is present. TTE is indicated for the investigation of aortic ulceration, atherosclerotic plaque and mural thrombotic material. TEE may be appropriate for documenting aortic lesions if embolic episodes are repetitive and surgical intervention is contemplated. Because of the posterior position of the thoracic aorta and the image span of the TEE window, TEE is a more definitive study of aortic dissection and aneurysm than TTE. In suspected aortic dissection and aortic trauma, TEE is frequently considered the diagnostic study of choice. 17. Interventional and Surgical TEE TEE can be of use during percutaneous and surgical cardiac interventions. In selected instances, TEE can provide guidance during the creation of shunts, placement of septation devices, performance of valvular plastic procedures and replacement, when the surgical result cannot be adequately assessed by other means. Prior to elective percutaneous mitral valvuloplasty, TEE is used to assess left atrial thrombi. TEE may be used to assess cardiac organ donors before harvesting decisions are made. In lung or heart-lung transplant, the integrity and morphology of pulmonary vascular anastomoses is critical. Intraoperative TEE can assist in surgical management decisions. In select high-risk patients, intraoperative TEE may monitor ventricular function, complementing hemodynamic monitoring data. Assessment for volume status and global and regional myocardial contractility can be therapeutically useful. However, routine use of TEE in non-high risk valvular surgeries or bypass surgeries such as CABG is not supported. 18. Arrhythmias Echocardiography is covered for assessment of patients with certain cardiac arrhythmias (atrial fibrillation, atrial flutter, ventricular tachycardia and ventricular fibrillation) to identify underlying structural or functional cardiac abnormalities identifiable by echocardiography and for which test results will influence treatment decisions. 19. Cardioversion When cardioversion is required to treat atrial fibrillation or flutter, an echocardiogram prior to the procedure may be reasonable and necessary when the patient is at high risk for embolization, such as those who: Have had an embolic event from atrial fibrillation in the past, Have had an adverse event following a previous attempt at cardioversion, Are not on anticoagulation therapy, Have been on inadequate anticoagulation therapy, or Have had previously demonstrated left atrial thrombus.

TEE may be of use in those patients for whom anticoagulation is contraindicated and therefore they are not anti-coagulated. When the patient is anti-coagulated adequately, TTE will usually suffice as a pre-treatment assessment for thrombi. 20. Palpitations and Syncope Echocardiography may be used to evaluate palpitations or syncope only when there is clinical suspicion of heart disease and when standard electrocardiography testing (resting ECG, 24 Hour Holter Monitoring, stress testing) have been negative or equivocal. 21. Difficult to Control Hypertension Echocardiography may be used to assess diastolic function in patients with difficult to control hypertension, for the guidance of treatment decisions. Echocardiography is not indicated for patients with controlled hypertension. 22. Pulmonary Heart Disease Echocardiography is useful in the evaluation and monitoring of right sided heart failure due to pulmonary hypertension or other types of pulmonary disease in which the right ventricle must pump against high pressures in the lungs. Frequency of periodic reassessment will be dictated by clinical status and interventions. 23. Transesophageal Cardiac Output Monitoring - Effective 5/17/2007, this service can be covered, when medically required, for ventilated ICU patients and inpatient/outpatient surgical patients. Change Request 5608 instructs providers to use unlisted CPT code 76999-26 for this service. Limitations 1. Echocardiographic studies are not payable by Medicare when they are not reasonable and necessary to obtain clinically significant diagnostic or monitoring information. The contractor will utilize recognized resources such as the American College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines in such determinations. 2. The utilization of contrast should not be routine protocol in the laboratory/office setting. Patients requiring contrast should be carefully selected and the decision to use contrast should be made following a pre-contrast study and an assessment of echocardiographic data. 3. Studies without, and then with, contrast will be considered a single study, whether performed on the same or sequential days. 4. Contrast echocardiography is not covered when used to evaluate perfusion. Training Requirements The following training requirements do not apply to hospital in-patient or out-patient echocardiography services. The contractor itself does not credential providers. Medicare does expect a

satisfactory level of competence from providers who submit claims for services rendered. Medicare services are only payable when performed by appropriate staff in an appropriate setting (explicitly stated in the Medicare Program Integrity Manual, Pub. 100-08, Chapter 13). Substandard studies are associated with unnecessary repetition of studies and overutilization of services. Substandard studies can directly endanger the patient if medical conditions are not able to be diagnosed because of a poorly or improperly conducted study, or, medical conditions are not recognized because the level of expertise of the interpreter does not meet accepted professional standards. The most commonly cited professional standard is that of the ACC/AHA (American College of Cardiology, American Hospital Association; For transthoracic echo, Level 1 experience is defined as not sufficient to perform or interpret echocardiograms independently, Level 2 experience is a level appropriate for independent practice of echocardiograms, and Level 3 experience is appropriate for a center director. The acceptable levels of competence are: For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions: 1. The service is performed personally by a physician with full training in cardiac structure and function, the acquisition of echocardiography images, echocardiographic equipment functions, and trouble shooting, e.g. similar to Level 2 experience of the ACC/AHA; or 2. The service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or 3. The service is performed at a laboratory (e.g. office, IDTF), credentialed by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL). Note that the national supervision level is 1 (general supervision) for TTE and 3 (personal supervision) for the technical component of TEE. You may find the current year CMS RVU/fee schedule database (e.g. PPRRVU06.xls, column Z) at www.cms.gov. For the professional portion (interpretation), an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting one of the following requirements: For Transthoraic Echocardiography (TTE) and/or Transesophageal Echocardiography (TEE): 1. The physician is ABIM board certified or board eligible in Cardiovascular Diseases; OR 2. The physician provides the interpretation in conjunction with a study that was performed at a laboratory that is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and that is subject

to such laboratory s quality assurance policies and procedures (the ICAEL website is http://www.icael.org/icael/main/icael_standards.htm. For Transthoracic Echocardiography (TTE): 1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography. Level II training is the basic level for independent practice. OR 2. The equivalent of Level II training of the ACC/AHA. This A/B MAC requires that this training must be obtained by working under a mentor who is fully qualified to teach and supervise, e.g. Level III training of the ACC/AHA. ( Training and competence are not demonstrated by prior reimbursement for multiple procedures by Medicare prior to the implementation of this LCD). OR 3. The physician has staff privileges to interpret hospital transthoracic echocardiograms at a hospital that participates in the Medicare program. This A/B MAC further requires that the physician must be authorized by the hospital to interpret any and all TTE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL. For Transesophageal Echocardiography (TEE), professional competence is fulfilled when: 1. The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, OR 2. NBE (National Board of Echocardiography) certification in TEE, OR 3. The equivalent of Level II training in TTE, AND additional training specific to TEE which should include: 1) A letter or certificate from the training supervisor (training program director, echocardiography laboratory director, or equivalent) documenting performance and interpretation of 50 supervised TEE cases, OR 4. The physician has staff privileges to interpret hospital TEE at a hospital that participates in the Medicare program. This A/B MAC further requires that the physician must be authorized by the hospital to interpret any and all TEE examinations and not just those obtained by him or herself. The hospital Echocardiography Laboratory must be accredited by ICAEL. OR 5. The provider performs cardiovascular anesthesiology with experience in TEE. Submission of claims implies compliance with training requirements The submission of claims for echocardiography will be considered an attestation that both the technical and professional components of the service were provided within the context of the above stated credentials.

When the diagnostic test is not performed by the treating physician or by a consulting physician who is providing full consultation services to the treating physician, the test must be ordered by the treating physician. Purchased Service A physician or group may bill the Medicare Program and receive Part B payment, on assignment, for the technical portion of an echocardiography study. The purchasing physician or group may be the same physician or group ordering the test. The supplier performing the technical component must be enrolled in the Medicare Program. The purchasing physician or group may not markup the charge from the purchase price, and must accept as full payment for the technical portion, the lowest amount when the Medicare Fee Schedule, the billing physician s actual charge and the supplier s net charge are compared. Limited Capability Ultrasound Scanners Some cardiac ultrasound machines have become increasingly compact and portable. Certain "hand carried" scanners are "full featured" and permit a skilled examiner to image and record permanent records of all of the tomographic images and doppler data (both color and spectral) needed to perform a complete transthoracic echocardiographic examination that may be quite comparable, in diagnostic value, to that obtained with larger, "state of the art" instruments. In order to qualify as a valid echocardiographic service, the study must be done for an accepted clinical indication by a properly trained examiner and must include a permanent record of the findings, data sufficient to support the conclusions and an appropriate interpretation and written report by a qualified interpretor. Such a study would meet the standards required for a complete echocardiographic examination, regardless of the size of the instrument used to perform the study. On the other hand, certain small scanners have more limited capabilities and lack either the permanent recording capabilities or some of the functional capabilities needed to perform a complete examination. Such a study may be quite useful as an extension of the physical examination, that is, as a bundled part of the E/M service. However, an examination that does not meet the standards required for a complete diagnostic echocardiographic examination whether performed with a "conventional" scanner or a limited capability ultrasound scanner will not be recognized as a valid echocardiographic service and will be non-covered. Transesophageal cardiac monitoring placement must be billed as 76999-26. Placement may be billed by an anesthesiologist, surgeon, or other physician (placement is not bundled with surgery or anesthesia). Monitoring is not separately billable; monitoring is covered similar to other services such as concurrent intraoperative care or ICU BP, O2, HR, temperature, and other monitoring. Coding Information 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. 999x Not Applicable 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. 99999 Not Applicable CPT/HCPCS Codes This A/B MAC does not identify specific HCPCS codes for contrast agents or isotopes in this LCD. Numerous new agents are approved throughout the year, or, current agents get assigned new HCPCS numbers. Contrast agents and isotopes are covered when used with their corresponding procedure. However, they may be reported separately. 76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) 93303 93304 93306 93307 93308 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; COMPLETE TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; FOLLOW-UP OR LIMITED STUDY ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, COMPLETE, WITHOUT SPECTRAL OR COLOR DOPPLER ECHOCARDIOGRAPHY ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY 93312 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING);

INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT 93313 93314 93315 93316 93317 93318 93320 93321 93325 A9700 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING) DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, PER STUDY ICD-9 Codes that Support Medical Necessity It is the provider s responsibility to avoid truncated codes by selecting a code(s) carried out to the highest level of specificity and selected from the ICD-9-CM book appropriate to the year in which the service was performed. It is not enough to link the procedure code to a correct, payable ICD-9-CM code. The diagnosis or clinical signs/symptoms must be present for the procedure to be paid. Conditions must be clinically significant. For example, the inclusion of codes such as 786.59 (chest pain) and 786.05 (shortness of breath) is intended to cover the processing of claims for patients where such symptoms are clinically significant in a setting where

echocardiography is clinically reasonable and necessary by community standards of necessary care. Further, these ICD-9-CM codes can be used only with the conditions listed in the Indications and Limitations section of this LCD. 038.0 STREPTOCOCCAL SEPTICEMIA 038.10 STAPHYLOCOCCAL SEPTICEMIA UNSPECIFIED 038.11 METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AUREUS SEPTICEMIA 038.12 METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS SEPTICEMIA 038.19 OTHER STAPHYLOCOCCAL SEPTICEMIA 038.2 PNEUMOCOCCAL SEPTICEMIA 038.3 SEPTICEMIA DUE TO ANAEROBES 038.40-038.44 SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISM UNSPECIFIED - SEPTICEMIA DUE TO SERRATIA 038.49 OTHER SEPTICEMIA DUE TO GRAM-NEGATIVE ORGANISMS 038.8 OTHER SPECIFIED SEPTICEMIAS 038.9 UNSPECIFIED SEPTICEMIA 074.21-074.23 COXSACKIE PERICARDITIS - COXSACKIE MYOCARDITIS 086.0 CHAGAS' DISEASE WITH HEART INVOLVEMENT 088.81 LYME DISEASE 093.0 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC 093.1 SYPHILITIC AORTITIS 093.21-093.24 SYPHILITIC ENDOCARDITIS OF MITRAL VALVE - SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE 093.81 SYPHILITIC PERICARDITIS 093.82 SYPHILITIC MYOCARDITIS 098.83 GONOCOCCAL PERICARDITIS 098.84 GONOCOCCAL ENDOCARDITIS

112.81 CANDIDAL ENDOCARDITIS 115.03 HISTOPLASMA CAPSULATUM PERICARDITIS 115.04 HISTOPLASMA CAPSULATUM ENDOCARDITIS 115.13 HISTOPLASMA DUBOISII PERICARDITIS 115.14 HISTOPLASMA DUBOISII ENDOCARDITIS 130.3 MYOCARDITIS DUE TO TOXOPLASMOSIS 135 SARCOIDOSIS 164.1 MALIGNANT NEOPLASM OF HEART 198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 199.2 MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN 212.7 BENIGN NEOPLASM OF HEART 238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES 275.01 HEREDITARY HEMOCHROMATOSIS 275.02 HEMOCHROMATOSIS DUE TO REPEATED RED BLOOD CELL TRANSFUSIONS 275.03 OTHER HEMOCHROMATOSIS 276.50 VOLUME DEPLETION, UNSPECIFIED 276.51 DEHYDRATION 276.52 HYPOVOLEMIA 276.61 TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD 276.69 OTHER FLUID OVERLOAD 277.30 AMYLOIDOSIS, UNSPECIFIED 277.31 FAMILIAL MEDITERRANEAN FEVER 277.39 OTHER AMYLOIDOSIS 324.0 INTRACRANIAL ABSCESS 324.1 INTRASPINAL ABSCESS

362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION 391.0-391.2 ACUTE RHEUMATIC PERICARDITIS - ACUTE RHEUMATIC MYOCARDITIS 391.8 OTHER ACUTE RHEUMATIC HEART DISEASE 392.0 RHEUMATIC CHOREA WITH HEART INVOLVEMENT 393 CHRONIC RHEUMATIC PERICARDITIS 394.0-394.2 MITRAL STENOSIS - MITRAL STENOSIS WITH INSUFFICIENCY 394.9 OTHER AND UNSPECIFIED MITRAL VALVE DISEASES 395.0-395.2 RHEUMATIC AORTIC STENOSIS - RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY 395.9 OTHER AND UNSPECIFIED RHEUMATIC AORTIC DISEASES 396.0-396.3 MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS - MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY 396.8 MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES 396.9 MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED 397.0 DISEASES OF TRICUSPID VALVE 397.1 RHEUMATIC DISEASES OF PULMONARY VALVE 397.9 RHEUMATIC DISEASES OF ENDOCARDIUM VALVE UNSPECIFIED 398.0 RHEUMATIC MYOCARDITIS 398.90 RHEUMATIC HEART DISEASE UNSPECIFIED 398.91 RHEUMATIC HEART FAILURE (CONGESTIVE) 401.0 MALIGNANT ESSENTIAL HYPERTENSION 401.1 BENIGN ESSENTIAL HYPERTENSION 401.9 UNSPECIFIED ESSENTIAL HYPERTENSION 402.00 402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

402.10 BENIGN HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE 402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE 402.90 402.91 404.00-404.03 404.10 404.11 404.13 404.90 404.91 404.93 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 405.01 MALIGNANT RENOVASCULAR HYPERTENSION 410.00-410.02 410.10-410.12 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE

410.20-410.22 410.30-410.32 410.40-410.42 410.50-410.52 410.60-410.62 410.70-410.72 410.80-410.82 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE 411.0 POSTMYOCARDIAL INFARCTION SYNDROME 411.1 INTERMEDIATE CORONARY SYNDROME 411.81 411.89 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER 412 OLD MYOCARDIAL INFARCTION 413.0 ANGINA DECUBITUS 413.1 PRINZMETAL ANGINA 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS 414.00-414.07 CORONARY ATHEROSCLEROSIS OF UNSPECIFIED TYPE OF VESSEL NATIVE OR GRAFT - CORONARY ATHEROSCLEROSIS OF BYPASS GRAFT (ARTERY) (VEIN) OF TRANSPLANTED HEART

414.10-414.12 ANEURYSM OF HEART (WALL) - DISSECTION OF CORONARY ARTERY 414.19 OTHER ANEURYSM OF HEART 414.3 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE 414.4 414.8 CORONARY ATHEROSCLEROSIS DUE TO CALCIFIED CORONARY LESION OTHER SPECIFIED FORMS OF CHRONIC ISCHEMIC HEART DISEASE 414.9 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED 415.0 ACUTE COR PULMONALE 415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION 415.13 SADDLE EMBOLUS OF PULMONARY ARTERY 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 416.0 PRIMARY PULMONARY HYPERTENSION 416.8 OTHER CHRONIC PULMONARY HEART DISEASES 417.0 ARTERIOVENOUS FISTULA OF PULMONARY VESSELS 417.1 ANEURYSM OF PULMONARY ARTERY 420.0 ACUTE PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE 420.90 ACUTE PERICARDITIS UNSPECIFIED 420.91 ACUTE IDIOPATHIC PERICARDITIS 420.99 OTHER ACUTE PERICARDITIS 421.0 ACUTE AND SUBACUTE BACTERIAL ENDOCARDITIS 421.1 ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 421.9 ACUTE ENDOCARDITIS UNSPECIFIED 422.0 ACUTE MYOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 422.90-422.93 ACUTE MYOCARDITIS UNSPECIFIED - TOXIC MYOCARDITIS 423.0-423.2 HEMOPERICARDIUM - CONSTRICTIVE PERICARDITIS

423.8 OTHER SPECIFIED DISEASES OF PERICARDIUM 423.9 UNSPECIFIED DISEASE OF PERICARDIUM 424.0-424.3 MITRAL VALVE DISORDERS - PULMONARY VALVE DISORDERS 424.90 ENDOCARDITIS VALVE UNSPECIFIED UNSPECIFIED CAUSE 424.91 ENDOCARDITIS IN DISEASES CLASSIFIED ELSEWHERE 424.99 OTHER ENDOCARDITIS VALVE UNSPECIFIED 425.0 ENDOMYOCARDIAL FIBROSIS 425.11 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY 425.18 OTHER HYPERTROPHIC CARDIOMYOPATHY 425.2 OBSCURE CARDIOMYOPATHY OF AFRICA 425.3 ENDOCARDIAL FIBROELASTOSIS 425.4 OTHER PRIMARY CARDIOMYOPATHIES 425.5 ALCOHOLIC CARDIOMYOPATHY 425.7-425.9 NUTRITIONAL AND METABOLIC CARDIOMYOPATHY - SECONDARY CARDIOMYOPATHY UNSPECIFIED 426.0 ATRIOVENTRICULAR BLOCK COMPLETE 426.10-426.12 426.2-426.4 ATRIOVENTRICULAR BLOCK UNSPECIFIED - MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK LEFT BUNDLE BRANCH HEMIBLOCK - RIGHT BUNDLE BRANCH BLOCK 426.7 ANOMALOUS ATRIOVENTRICULAR EXCITATION 426.9 CONDUCTION DISORDER UNSPECIFIED 427.0 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA 427.1 PAROXYSMAL VENTRICULAR TACHYCARDIA 427.2 PAROXYSMAL TACHYCARDIA UNSPECIFIED 427.31 ATRIAL FIBRILLATION 427.32 ATRIAL FLUTTER

427.41 VENTRICULAR FIBRILLATION 427.42 VENTRICULAR FLUTTER 427.5 CARDIAC ARREST 427.60-427.61 PREMATURE BEATS UNSPECIFIED - SUPRAVENTRICULAR 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 CONGESTIVE HEART FAILURE UNSPECIFIED 428.1 LEFT HEART FAILURE 428.20-428.23 428.30-428.33 428.40-428.43 UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.9 HEART FAILURE UNSPECIFIED 429.0-429.6 MYOCARDITIS UNSPECIFIED - RUPTURE OF PAPILLARY MUSCLE 429.71 429.79 CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED OTHER 429.81 OTHER DISORDERS OF PAPILLARY MUSCLE 429.89 OTHER ILL-DEFINED HEART DISEASES 429.9 HEART DISEASE UNSPECIFIED 434.00 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION 434.01 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION

434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION 434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION 434.90 434.91 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION 435.8 OTHER SPECIFIED TRANSIENT CEREBRAL ISCHEMIAS 435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE 440.0 ATHEROSCLEROSIS OF AORTA 441.00 DISSECTION OF AORTA ANEURYSM UNSPECIFIED SITE 441.01 DISSECTION OF AORTA THORACIC 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.1-441.7 THORACIC ANEURYSM RUPTURED - THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE 442.0-442.2 ANEURYSM OF ARTERY OF UPPER EXTREMITY - ANEURYSM OF ILIAC ARTERY 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 442.81-442.84 ANEURYSM OF ARTERY OF NECK - ANEURYSM OF OTHER VISCERAL ARTERY 442.89 ANEURYSM OF OTHER SPECIFIED SITE 442.9 OTHER ANEURYSM OF UNSPECIFIED SITE 443.0 RAYNAUD'S SYNDROME 443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) 443.21-443.24 DISSECTION OF CAROTID ARTERY - DISSECTION OF VERTEBRAL ARTERY 443.29 DISSECTION OF OTHER ARTERY 443.81 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE

443.89 OTHER PERIPHERAL VASCULAR DISEASE 443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 444.21 ARTERIAL EMBOLISM AND THROMBOSIS OF UPPER EXTREMITY 444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 444.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED ARTERY 445.01 ATHEROEMBOLISM OF UPPER EXTREMITY 445.02 ATHEROEMBOLISM OF LOWER EXTREMITY 445.81 ATHEROEMBOLISM OF KIDNEY 445.89 ATHEROEMBOLISM OF OTHER SITE 446.1 ACUTE FEBRILE MUCOCUTANEOUS LYMPH NODE SYNDROME (MCLS) 446.7 TAKAYASU'S DISEASE 447.70 AORTIC ECTASIA, UNSPECIFIED SITE 447.71 THORACIC AORTIC ECTASIA 458.0 ORTHOSTATIC HYPOTENSION 458.21 HYPOTENSION OF HEMODIALYSIS 458.29 OTHER IATROGENIC HYPOTENSION 458.8 OTHER SPECIFIED HYPOTENSION 458.9 HYPOTENSION UNSPECIFIED 459.2 COMPRESSION OF VEIN 518.4 ACUTE EDEMA OF LUNG UNSPECIFIED 518.82 OTHER PULMONARY INSUFFICIENCY NOT ELSEWHERE CLASSIFIED

571.0-571.3 ALCOHOLIC FATTY LIVER - ALCOHOLIC LIVER DAMAGE UNSPECIFIED 571.40-571.42 CHRONIC HEPATITIS UNSPECIFIED - AUTOIMMUNE HEPATITIS 571.49 OTHER CHRONIC HEPATITIS 571.5-571.9 674.82 CIRRHOSIS OF LIVER WITHOUT ALCOHOL - UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL OTHER COMPLICATIONS OF PUERPERIUM WITH DELIVERY WITH POSTPARTUM COMPLICATION 674.84 OTHER COMPLICATIONS OF PUERPERIUM 710.0 SYSTEMIC LUPUS ERYTHEMATOSUS 745.0 COMMON TRUNCUS 745.10-745.12 COMPLETE TRANSPOSITION OF GREAT VESSELS - CORRECTED TRANSPOSITION OF GREAT VESSELS 745.19 OTHER TRANSPOSITION OF GREAT VESSELS 745.2-745.5 TETRALOGY OF FALLOT - OSTIUM SECUNDUM TYPE ATRIAL SEPTAL DEFECT 745.60 ENDOCARDIAL CUSHION DEFECT UNSPECIFIED TYPE 745.61 OSTIUM PRIMUM DEFECT 745.69 OTHER ENDOCARDIAL CUSHION DEFECTS 745.7-745.9 COR BILOCULARE - UNSPECIFIED DEFECT OF SEPTAL CLOSURE 746.00-746.02 CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - STENOSIS OF PULMONARY VALVE CONGENITAL 746.09 OTHER CONGENITAL ANOMALIES OF PULMONARY VALVE 746.1-746.7 746.81-746.85 TRICUSPID ATRESIA AND STENOSIS CONGENITAL - HYPOPLASTIC LEFT HEART SYNDROME SUBAORTIC STENOSIS CONGENITAL - CORONARY ARTERY ANOMALY CONGENITAL 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 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) 747.11 INTERRUPTION OF AORTIC ARCH 747.20-747.22 CONGENITAL ANOMALY OF AORTA UNSPECIFIED - CONGENITAL ATRESIA AND STENOSIS OF AORTA 747.29 OTHER CONGENITAL ANOMALIES OF AORTA 747.31 PULMONARY ARTERY COARCTATION AND ATRESIA 747.32 PULMONARY ARTERIOVENOUS MALFORMATION 747.39 747.40-747.42 OTHER ANOMALIES OF PULMONARY ARTERY AND PULMONARY CIRCULATION CONGENITAL ANOMALY OF GREAT VEINS UNSPECIFIED - PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION 747.49 OTHER ANOMALIES OF GREAT VEINS 759.3 SITUS INVERSUS 759.82 MARFAN SYNDROME 770.81 PRIMARY APNEA OF NEWBORN 770.82 OTHER APNEA OF NEWBORN 770.89 OTHER RESPIRATORY PROBLEMS AFTER BIRTH 771.83 BACTEREMIA OF NEWBORN 779.81 NEONATAL BRADYCARDIA 779.82 NEONATAL TACHYCARDIA 779.89 OTHER SPECIFIED CONDITIONS ORIGINATING IN THE PERINATAL PERIOD 780.01 COMA 780.02 TRANSIENT ALTERATION OF AWARENESS 780.2 SYNCOPE AND COLLAPSE 780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED 780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED

780.60 FEVER, UNSPECIFIED 780.61 FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE 780.62 POSTPROCEDURAL FEVER 780.63 POSTVACCINATION FEVER 780.64 CHILLS (WITHOUT FEVER) 780.65 HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE 782.3 EDEMA 782.5 CYANOSIS 784.3 APHASIA 785.1 PALPITATIONS 785.2 UNDIAGNOSED CARDIAC MURMURS 785.3 OTHER ABNORMAL HEART SOUNDS 785.50-785.52 SHOCK UNSPECIFIED - SEPTIC SHOCK 785.59 OTHER SHOCK WITHOUT TRAUMA 786.03-786.07 APNEA - WHEEZING 786.09 RESPIRATORY ABNORMALITY OTHER 786.50 UNSPECIFIED CHEST PAIN 786.51 PRECORDIAL PAIN 786.59 OTHER CHEST PAIN 790.7 BACTEREMIA 794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) 807.4 FLAIL CHEST 861.00-861.03 UNSPECIFIED INJURY OF HEART WITHOUT OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS WITHOUT OPEN WOUND INTO THORAX

861.10-861.13 UNSPECIFIED INJURY OF HEART WITH OPEN WOUND INTO THORAX - LACERATION OF HEART WITH PENETRATION OF HEART CHAMBERS AND OPEN WOUND INTO THORAX 901.0 INJURY TO THORACIC AORTA 901.2 INJURY TO SUPERIOR VENA CAVA 901.41 INJURY TO PULMONARY ARTERY 901.42 INJURY TO PULMONARY VEIN 958.0 AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 958.1 FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA 958.4 TRAUMATIC SHOCK 963.1 POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS 990 EFFECTS OF RADIATION UNSPECIFIED 994.8 995.20 ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC CURRENT UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE 995.22 UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA 995.23 UNSPECIFIED ADVERSE EFFECT OF INSULIN 995.29 996.00-996.04 996.09 996.1 996.60-996.63 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT - MECHANICAL COMPLICATION OF AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR OTHER MECHANICAL COMPLICATION OF CARDIAC DEVICE IMPLANT AND GRAFT MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT INFECTION AND INFLAMMATORY REACTION DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT - INFECTION AND INFLAMMATORY REACTION DUE TO NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT

996.66 INFECTION AND INFLAMMATORY REACTION DUE TO INTERNAL JOINT PROSTHESIS 996.71 OTHER COMPLICATIONS DUE TO HEART VALVE PROSTHESIS 996.72 OTHER COMPLICATIONS DUE TO OTHER CARDIAC DEVICE IMPLANT AND GRAFT 996.83 COMPLICATIONS OF TRANSPLANTED HEART 996.84 COMPLICATIONS OF TRANSPLANTED LUNG 997.1 CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED 998.01 POSTOPERATIVE SHOCK, CARDIOGENIC 998.51 INFECTED POSTOPERATIVE SEROMA 998.59 OTHER POSTOPERATIVE INFECTION 999.1 999.31 AIR EMBOLISM AS A COMPLICATION OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED OTHER AND UNSPECIFIED INFECTION DUE TO CENTRAL VENOUS CATHETER 999.32 BLOODSTREAM INFECTION DUE TO CENTRAL VENOUS CATHETER 999.33 LOCAL INFECTION DUE TO CENTRAL VENOUS CATHETER 999.34 999.39 V15.1 ACUTE INFECTION FOLLOWING TRANSFUSION, INFUSION, OR INJECTION OF BLOOD AND BLOOD PRODUCTS INFECTION FOLLOWING OTHER INFUSION, INJECTION, TRANSFUSION, OR VACCINATION PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH V42.1 HEART REPLACED BY TRANSPLANT V42.2 HEART VALVE REPLACED BY TRANSPLANT V42.6 LUNG REPLACED BY TRANSPLANT V43.21 HEART REPLACED BY HEART ASSIST DEVICE V43.22 HEART REPLACED BY FULLY IMPLANTABLE ARTIFICIAL HEART V43.3 HEART VALVE REPLACED BY OTHER MEANS

V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.12 ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V59.8 DONORS OF OTHER SPECIFIED ORGAN OR TISSUE V72.81 PRE-OPERATIVE CARDIOVASCULAR EXAMINATION V72.83 OTHER SPECIFIED PRE-OPERATIVE EXAMINATION Diagnoses that Support Medical Necessity Any diagnoses consistent with the Indications and Limitations of Coverage and/or Medical Necessity section, or the ICD-9-CM descriptors in the ICD-9-CM Codes That Support Medical Necessity section. ICD-9 Codes that DO NOT Support Medical Necessity ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation Diagnoses that DO NOT Support Medical Necessity Any diagnoses inconsistent with the Indications and Limitations of Coverage and/or Medical Necessity section, or the ICD-9-CM descriptors in the ICD-9-CM Codes That Support Medical Necessity section. General Information Documentations Requirements Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned. Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. The quality of images obtained on any given exam is dependent on the instrumentation, the operator and the patient. At a minimum, a complete study should contain M mode and/or 2D measurements of LV end diastolic diameter, LV end systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion and a qualitative description of the LV function, whenever possible given any technical limitations in a particular case. Individual echocardiographic laboratories (providers) may chose valid substitutes for these parameters such as LV volumes, ejection fraction and mass measurements. A Doppler interrogation should state the modes used and should give both qualitative and quantitative information where appropriate. Claims for contrast echocardiography services must be supported by documentation that conventional studies were inconclusive and there was a need for the contrast

enhancement. Documentation must be available to Medicare upon request. Appendices According to national regulations, clinics which are (a) not physician owned and which are (b) billing Medicare primarily for diagnostic tests may be required to enroll as IDTFs. For example, a nonphysician owner who establishes an echocardiography testing clinic by leasing office space, equipment, and hiring technicians, and hires a retired ophthalmologist to provide off-site (general) supervision of diagnostic testing without treatment would be more appropriately enrolled as an IDTF rather than merely billing all services through the physician's PIN. Utilization Guidelines Repeat echocardiographic studies should be guided by the clinical status of the patient. The frequency of services is governed by the circumstances outlined in the Indications and Limitations section of this policy. Repeat studies are appropriate to monitor changes in cardiac structure or function when there are clinical changes in the status of the patient, or when disease progression is otherwise suspected. In order to ensure that only necessary services are paid, and to assist anomalous providers in meeting Medicare norms, services may be selected for medical review based on frequencies inconsistent with community norms or repetitive use of generic diagnoses such as chest pain. Sources of Information and Basis for Decision American College of Cardiology, Guidelines for the Clinical Application of Echocardiography, Available at: http://http://www.med.umich.edu/anescriticalcare/documents/guidelines/am% 20Col%20Cardio%20Found/echocardiography.pdf Accessed June 4, 2012. Quinones MA, Douglas PS, Foster E, Gorcsan J, Lewis, FJ, Pearlman AS, et al. ACC/AHA Clinical Competence Statement on Echocardiography. J AM Col Cardio. 2003;41(4):687-708. Otto CM. The Practice of Clinical Echocardiography. 2nd ed. Philadelphia, PA: W.B. Saunders Company; 2002. Braunwald. E. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Philadelphia, PA: W.B. Saunders Company; 2001. CMD Cardiology Work Group Atrioventricular Nodal Reentry Tachycardia. Available at: http://emedicine.medscape.com/article/160215-overview Accessed 6/4/2012. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography." Journal of the American College of Cardiology. 2003;42:954-70 Note: Some of the references used in the development of the original policy may no longer be available. Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community.

Contractor Advisory Committee meeting dates: California - Hawaii - Nevada - Start Date of Comment Period End Date of Comment Period Start Date of Notice Period 06/16/2008 Revision History Number Revision #12 Revision History Explanation Revision #12 effective for dates of service on or after 06/14/2012 Revision made: Under CMS National Coverage Policy, Pub. 100-08, Chapter 3, Section 3.4.1.3B changed to read 3.4.1.3 to include all of this section. Sources of Information and Basis for Decision, updates web addresses for two references American College of Cardiology, Guidelines for the Clinical Application of Echocardiography and Atrioventricular Nodal Reentry Tachycardia. This LCD is being updated due to annual review. Revision #11 effective for dates of service on or after 10/01/2011 Under ICD-9 Codes that Support Medical Necessity deleted 425.1, 444.0, 518.5, 747.3, 998.0 & 999.4 and added 414.4, 415.13, 425.11, 425.18, 747.31, 747.32, 747.39, 998.01, 999.32, 999.33 & 999.34. The verbiage for 999.31 was revised. This LCD is being revised due to the annual FY 2012 ICD-9-CM code update. This revision will become effective 10/01/2011. Revision 10 effective for dates of service on or after 07/14/2011 Revisions made: Under 'CMS National Coverage Policy' updated Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.3,B as this section was updated on 6-28-11. Under Indications and Limitations of Coverage and/or Medical Necessity subheading Training Requirements, physician number 2, updated website for Intersocietal Commission for the Accreditation of Echocardiography Laboratories to now read - http://www.icael.org/icael/main/icael_standards.htm. Under Sources of Information and basis for Decision updated reference web site address for article Atrioventricular Nodal Reentry Tachycardia. Removed citation reference, ICAEL online American College of Cardiology, Guidelines for Clinical application of Echocardiography, available at: www.acc.org to now read "ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography." Journal of the American College of Cardiology. 2003;42:954-70. Removed the reference citation of NE, excerpt from newsletter January 2005, Training Requirements. Available at: www.icael.org/icael/news/articles/floridatte.htm, as this website is no longer available and the article was not able to be located. Revision 9 Effective for dates of service on or after 11/12/2010 Revisions made: Under CMS National Coverage Policy, the citation of Medicare Program Integrity Manual, Pub. 100-08 Chapter 3, Section 3.4.1.1.E was updated to reflect the new citation for diagnosis requirement (G). Under Sources of Information and Basis for Decision removed "Other contractor s Local Coverage Determinations, including Empire Medicare Services, 00803, L3123", as this LCD was not accessible.

Revision #8 effective for dates of service on or after 10-01-10 Revision made: Under ICD-9 Codes that Support Medical Necessity, the following codes were added per the Annual Update of International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) per CR 7006 Transmittal 2017, and dated August 4, 2010: 275.01, 275.02, 275.03, 276.61, 276.69, 447.70 and 447.71. Revision #7 Revision made: Under Under ICD-9 Codes that Support Medical Necessity added ICD-9 codes 571.0-571.3, 571.40-571.42, 571.49, 571.5-571.9, V72.81 Revision #6 effective for dates of service on or after 05/27/2010 Revision made: Under Indications and Limitations of Coverage and/or Medical Necessity" subheading Technical Portion CMS internet domain name was changed from cms.hhs.gov to cms.gov. Revision #5 effective for dates of service on or after 11/12/2009 Revisions made: Under CMS National Coverage Policy specified specific citation sections for Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 60, 60.1, 60.2. Deleted reference Pub. 100-08 Medicare Program Integrity Manual, Chapter 13, Section 13.5.1 as this section is being revised and moved after 01/01/2010. Annual review and validation completed. Revision #4, 02/26/2009 This LCD is being revised to implement the streamlining of the Part B LCDs per the published article Palmetto Team to Streamline Part B LCDs in Jurisdiction 1 (J1). This article can be viewed at www.palmettogba.com by searching for the above article name. This revision will become effective on 02/26/2009. Revision #3, 01/01/2009 Revisions made: Annual 2009 CPT/HCPCS update, under CPT/HCPCS section of LCD added CPT code 93306, CPT codes 93307, 93308, 93312, 93313, 93314 descriptors revised. This LCD becomes effective 01/01/2009. Revision #2, 10/01/2008 This LCD is being revised due to the annual FY 2009 ICD-9-CM code update. Under "ICD-9 Codes that Support Medical Necessity" section added 038.12, 199.2 and 414.3. The verbiage for ICD-9 code 038.11 was revised. Sources of Information and Basis for Decision section the references were put in AMA citation format and duplicate references were removed. Under the Indications and Limitations for Coverage section duplicate CMS Manual and Federal Regulation citations were removed. The referenced manual citations within the Appendices section of the LCD were removed. This revision will become effective 10/01/2008. Revision #1, 09/02/2008 This LCD is being revised to add Bill Type 999X because the automated system transcription process was incomplete. 08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update. 11/09/2008 - The description for CPT/HCPCS code 93307 was changed in group 1 11/09/2008 - The description for CPT/HCPCS code 93308 was changed in group 1 11/09/2008 - The description for CPT/HCPCS code 93312 was changed in group 1

11/09/2008 - The description for CPT/HCPCS code 93313 was changed in group 1 11/09/2008 - The description for CPT/HCPCS code 93314 was changed in group 1 09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document: 93306 descriptor was changed in Group 1 93307 descriptor was changed in Group 1 93308 descriptor was changed in Group 1 93320 descriptor was changed in Group 1 93321 descriptor was changed in Group 1 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update. Reason for Change Maintenance (annual review with new changes, formatting, etc.) Related Documents This LCD has no Related Documents. LCD Attachments There are no attachments for this LCD. All Versions Updated on 06/05/2012 with effective dates 06/14/2012 - N/A Updated on 09/02/2011 with effective dates 10/01/2011-06/13/2012 Updated on 07/08/2011 with effective dates 07/14/2011-09/30/2011 Updated on 11/21/2010 with effective dates 11/12/2010-07/13/2011 Updated on 11/05/2010 with effective dates 11/12/2010 - N/A Some older versions have been archived. Please visit the MCD Archive Site retrieve them. to Read the LCD Disclaimer 64