Lcal Cverage Determinatin (LCD): Pulmnary Stress Testing (L32765) Cntractr Name Nvitas Slutins, Inc. LCD Infrmatin Dcument Infrmatin LCD ID Number L32765 LCD Title Pulmnary Stress Testing Cntractr's Determinatin Number L32765 Oversight Regin Regin I Regin X AMA CPT/ADA CDT Cpyright Statement CPT nly cpyright 2002-2013 American Medical Assciatin. All Rights Reserved. CPT is a registered trademark f the American Medical Assciatin. Applicable FARS/DFARS Apply t Gvernment Use. Fee schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT, and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein. The Cde n Dental Prcedures and Nmenclature (Cde) is published in Current Dental Terminlgy (CDT). Cpyright American Dental Assciatin. All rights reserved. CDT and CDT-2010 are trademarks f the American Dental Assciatin. Original Determinatin Effective Date Fr services perfrmed n r after 08/13/2012 Original Determinatin Ending Date ANTICIPATED 10/31/2013 Revisin Effective Date Fr services perfrmed n r after 11/19/2012 Revisin Ending Date CMS Natinal Cverage Plicy This LCD supplements but des nt replace, mdify r supersede existing Medicare applicable Natinal Cverage Determinatins (NCDs) r payment plicy rules and regulatins fr pulmnary stress testing. Federal statute and subsequent Medicare regulatins regarding prvisin and payment fr medical services are
lengthy. They are nt repeated in this LCD. Neither Medicare payment plicy rules nr this LCD replace, mdify r supersede applicable state statutes regarding medical practice r ther health practice prfessins acts, definitins and/r scpes f practice. All prviders wh reprt services fr Medicare payment must fully understand and fllw all existing laws, regulatins and rules fr Medicare payment fr pulmnary stress testing and must prperly submit nly valid claims fr them. Please review and understand them and apply the medical necessity prvisins in the plicy within the cntext f the manual rules. Relevant CMS manual instructins and plicies regarding pulmnary stress testing are fund in the fllwing Internet-Only Manuals (IOMs) published n the CMS Web site: Medicare Benefit Plicy Manual Pub. 100-02. Medicare Natinal Cverage Determinatins Manual Pub. 100-03. Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub. 100-09, Chapter 5. Scial Security Act (Title XVIII) Standard References, Sectins: 1862 (a)(1)(a) Medically Reasnable Necessary. 1862 (a)(1)(d) Investigatinal r Experimental. 1862 (a)(7) Screening (Rutine Physical Checkups). 1833 (e) Incmplete Claim. Jurisdictin H Ntice: Jurisdictin H cmprises the states f Arkansas, Luisiana, Mississippi, Clrad, New Mexic, Oklahma, and Texas. Nvitas is respnsible fr claims payment and Lcal Cverage Determinatin (LCD) develpment fr this jurisdictin. This LCD was created as a part f the legacy transitin (8/13/2012 11/19/2012); and, is a cnslidatin f the previus legacy cntractrs plicies. Cverage f each LCD begins when the state/cntract number cmbinatin fficially is integrated int the Jurisdictin. On the CMS MCD, this date is knwn as either the Original Effective Date r the Revisin Effective Date. The fllwing table details the fficial effective dates fr each state/cntract number cmbinatin. ST Legacy A Legacy B J "H" MAC A J "H" MAC B J "H" Cntractr Cntractr Cntractr Cntractr Effective Date Cntract Number Cntract Number Cntract Number Cntract Number AR PBSI: 00520 (J7) Nvitas: 07102 08/13/12 LA PBSI: 00528 (J7) Nvitas: 07202 08/13/12 AR PBSI: 00020 (J7) Nvitas: 07101 08/20/12 LA PBSI: 00233 (J7) Nvitas: 07201 08/20/12 MS PBSI: 00233 (J7) Nvitas: 07301 08/20/12 MS Cahaba: 00512 (J7) Nvitas: 07302 10/22/12 J 4 States Trailblazer: 04901 Nvitas: 04911 10/29/12
ST Legacy A Legacy B J "H" MAC A J "H" MAC B J "H" Cntractr Cntractr Cntractr Cntractr Effective Date Cntract Number Cntract Number Cntract Number Cntract Number CO Trailblazer: 04101 Nvitas: 04111 10/29/12 NM Trailblazer: 04201 Nvitas: 04211 10/29/12 OK Trailblazer: 04301 Nvitas: 04311 10/29/12 TX Trailblazer: 04401 Nvitas: 04411 10/29/12 CO Trailblazer: 04102 Nvitas: 04112 11/19/12 NM Trailblazer: 04202 Nvitas: 04212 11/19/12 OK Trailblazer: 04302 Nvitas: 04312 11/19/12 TX Trailblazer: 04402 Nvitas: 04412 11/19/12 Cverage Indicatins Limitatins and/r Medical Necessity Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier. Exercise testing is dne t evaluate functinal capacity and t assess the severity and type f impairment f existing, as well as undiagnsed, cnditins. The pulmnary stress test will be cnsidered medically necessary fr these cnditins: T determine whether the patient s exercise intlerance is related t pulmnary disease and nt cardiac disease, lack f cnditining r pr effrt. Initial diagnstic wrkup, when symptms, generally dyspnea, are ut f prprtin t findings n static functin (spirmetry, lung vlume and diffusin capacity). Detectin f interstitial lung disease (fibrsis) r exercise-induced brnchspasm, which are nly manifested by exercise. T evaluate patient's respnse t a newly established pulmnary treatment regimen. Abnrmal results n the Stage I prtcl may indicate that mre precise infrmatin is required thrugh mre cmplex Stage 2 prtcls. If Stage 3 prtcls are implemented, arterial bld analysis is necessary. In 75 percent f patients, Stage 1 is sufficient. T determine the xygen needs fr imprving exercise tlerance and increased functinal capacity, xygen titratin can be dne during graded exercise. Abslute cntraindicatins t exercise testing include: Acute febrile illness. Pulmnary edema. Systlic BP > 250 mm Hg. Diastlic BP > 120 mm Hg. Acute asthma attack. Unstable angina. Acute mycarditis.
Ntice: This LCD impses diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr medical necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatins, and all Medicare payment rules. As published in CMS IOM 100-08, Sectin 13.5.1, in rder t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under Sectin 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000, that meet the requirements f the Clinical Trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient s cnditin r t imprve the functin f a malfrmed bdy member. Furnished in a setting apprpriate t the patient s medical needs and cnditin. Ordered and furnished by qualified persnnel. One that meets, but des nt exceed, the patient s medical needs. At least as beneficial as an existing and available medically apprpriate alternative. Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 011x Hspital Inpatient (Including Medicare Part A) 012x 013x Hspital Inpatient (Medicare Part B nly) Hspital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x 023x 071x 073x 075x 077x 083x Skilled Nursing - Inpatient (Medicare Part B nly) Skilled Nursing - Outpatient Clinic - Rural Health Clinic - Freestanding Clinic - Cmprehensive Outpatient Rehabilitatin Facility (CORF) Clinic - Federally Qualified Health Center (FQHC) Ambulatry Surgery Center
085x Critical Access Hspital Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: The cntractr has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed. CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM) Publicatin 100-04 Claims Prcessing Manual fr further guidance. 0410 Respiratry Services - General Classificatin 0412 Respiratry Services - Inhalatin Services 0419 Respiratry Services - Other Respiratry Services 046X Pulmnary Functin - General Classificatin CPT/HCPCS Cdes Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. The American Medical Assciatin (AMA) and the Centers fr Medicare Medicaid Services (CMS) require the use f shrt CPT descriptrs in plicies published n the Web. 94620 Pulmnary stress test/simple 94621 Pulm stress test/cmplex ICD-9 Cdes that Supprt Medical Necessity The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a cvered diagnsis is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Nte: Prviders shuld cntinue t submit ICD-9-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. Medicare is establishing the fllwing limited cverage fr CPT/HCPCS cdes 94620 and 94621: Cvered fr: 135 SARCOIDOSIS 162.0 MALIGNANT NEOPLASM OF TRACHEA 162.2-162.5 162.8-162.9 MALIGNANT NEOPLASM OF MAIN BRONCHUS - MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED 197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG
197.3 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS 212.2-212.3 BENIGN NEOPLASM OF TRACHEA - BENIGN NEOPLASM OF BRONCHUS AND LUNG 231.2 CARCINOMA IN SITU OF BRONCHUS AND LUNG 415.0 ACUTE COR PULMONALE 415.11-415.13 IATROGENIC PULMONARY EMBOLISM AND INFARCTION - SADDLE EMBOLUS OF PULMONARY ARTERY 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 446.20 HYPERSENSITIVITY ANGIITIS UNSPECIFIED 466.0 ACUTE BRONCHITIS 466.11 ACUTE BRONCHIOLITIS DUE TO RESPIRATORY SYNCYTIAL VIRUS (RSV) 466.19 ACUTE BRONCIOLITIS DUE TO OTHER INFECTIOUS ORGANISMS 490 BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC 491.0-491.1 491.20-491.22 491.8-491.9 SIMPLE CHRONIC BRONCHITIS - MUCOPURULENT CHRONIC BRONCHITIS OBSTRUCTIVE CHRONIC BRONCHITIS WITHOUT EXACERBATION - OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS OTHER CHRONIC BRONCHITIS - UNSPECIFIED CHRONIC BRONCHITIS 492.0 EMPHYSEMATOUS BLEB 492.8 OTHER EMPHYSEMA 493.00-493.02 493.10-493.12 EXTRINSIC ASTHMA UNSPECIFIED - EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION INTRINSIC ASTHMA UNSPECIFIED - INTRINSIC ASTHMA WITH (ACUTE) EXACERBATION 493.20 CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED 493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION 493.81-493.82 493.90-493.92 EXERCISE-INDUCED BRONCHOSPASM - COUGH VARIANT ASTHMA ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 494.0 BRONCHIECTASIS WITHOUT ACUTE EXACERBATION 495.0-495.9 FARMERS' LUNG - UNSPECIFIED ALLERGIC ALVEOLITIS AND PNEUMONITIS
496 CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 500 COAL WORKERS' PNEUMOCONIOSIS 501 ASBESTOSIS 502 PNEUMOCONIOSIS DUE TO OTHER SILICA OR SILICATES 503 PNEUMOCONIOSIS DUE TO OTHER INORGANIC DUST 504 PNEUMONOPATHY DUE TO INHALATION OF OTHER DUST 505 PNEUMOCONIOSIS UNSPECIFIED 508.0-508.2 508.8-508.9 ACUTE PULMONARY MANIFESTATIONS DUE TO RADIATION - RESPIRATORY CONDITIONS DUE TO SMOKE INHALATION RESPIRATORY CONDITIONS DUE TO OTHER SPECIFIED EXTERNAL AGENTS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT 515 POSTINFLAMMATORY PULMONARY FIBROSIS 517.1-517.2 RHEUMATIC PNEUMONIA - LUNG INVOLVEMENT IN SYSTEMIC SCLEROSIS 517.8 LUNG INVOLVEMENT IN OTHER DISEASES CLASSIFIED ELSEWHERE 518.0-518.3 518.51-518.53 PULMONARY COLLAPSE - PULMONARY EOSINOPHILIA ACUTE RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY - ACUTE AND CHRONIC RESPIRATORY FAILURE FOLLOWING TRAUMA AND SURGERY 518.6 ALLERGIC BRONCHOPULMONARY ASPERGILLIOSIS 518.81-518.84 ACUTE RESPIRATORY FAILURE - ACUTE AND CHRONIC RESPIRATORY FAILURE 518.89 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED 519.11 ACUTE BRONCHOSPASM 519.19 OTHER DISEASES OF TRACHEA AND BRONCHUS 519.4 DISORDERS OF DIAPHRAGM 519.8 OTHER DISEASES OF RESPIRATORY SYSTEM NOT ELSEWHERE CLASSIFIED 714.81 RHEUMATOID LUNG 737.30 SCOLIOSIS (AND KYPHOSCOLIOSIS) IDIOPATHIC 780.51 INSOMNIA WITH SLEEP APNEA, UNSPECIFIED 780.53 HYPERSOMNIA WITH SLEEP APNEA, UNSPECIFIED 780.57 UNSPECIFIED SLEEP APNEA 786.02 ORTHOPNEA
786.03-786.07 APNEA - WHEEZING 786.09 RESPIRATORY ABNORMALITY OTHER 786.2 COUGH 786.30 HEMOPTYSIS, UNSPECIFIED 786.39 OTHER HEMOPTYSIS 793.11 SOLITARY PULMONARY NODULE 793.19 OTHER NONSPECIFIC ABNORMAL FINDING OF LUNG FIELD V72.82 PRE-OPERATIVE RESPIRATORY EXAMINATION Diagnses that Supprt Medical Necessity N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity N/A ICD-9 Cdes that DO NOT Supprt Medical Necessity Asterisk Explanatin Diagnses that DO NOT Supprt Medical Necessity All diagnses nt listed in the ICD-9-CM Cdes That Supprt Medical Necessity sectin f this LCD. General Infrmatin Dcumentatin Requirements Dcumentatin supprting medical necessity shuld be legible, maintained in the patient s medical recrd and made available t Medicare upn request. Medical recrd dcumentatin must indicate the medical necessity fr perfrming the test. Dcumentatin that the service and all it cmpnents were perfrmed, including the results f the pulmnary stress test, shuld be available. This infrmatin is nrmally fund in the ffice ntes, prgress ntes, histry and physical, and/r hard cpy f the test results. If the prvider f the service is ther than the rdering/referring physician, the prvider f the service must maintain hard cpy dcumentatin f test results and interpretatins, alng with cpies f the rdering/referring physician s rder fr the studies. The physician must indicate the clinical indicatin/medical necessity fr the study in his rder fr the test. Appendices N/A Utilizatin Guidelines N/A Surces f Infrmatin and Basis fr Decisin Other Cntractr Lcal Cverage Determinatins Pulmnary Stress Testing, TrailBlazer LCD, (00400) L7518, (00900) L11907. Nvitas Slutins, Inc. JH Lcal Cverage Determinatin (LCD) Cnslidatin, Narrative Justificatin Mst Clinically Apprpriate LCD LCDs Cmpared: L26497, Pulmnary Stress Testing, TrailBlazer, CO, NM, TX, OK A/B
CMD Ratinale: This is the nly LCD addressing this type f testing. The Indicatins/Limitatins is well written. Cntraindicatins t testing are als included. CPT and ICD-9 cding appears apprpriate. Dcumentatin Requirements is als present. Surces f Infrmatin and Basis fr Decisin are nt available as TrailBlazer adpted the LCD frm anther TrailBlazer LCD during the J4 transitin. L26497 is the mst clinically apprpriate LCD. Advisry Cmmittee Meeting Ntes Start Date f Cmment Perid End Date f Cmment Perid Start Date f Ntice Perid 06/28/2012 Revisin Histry Number 5 Revisin Histry Explanatin 11/19/2012 (Revisin Histry Number 5) Per CMS Change Request (CR) 7812, this LCD has been updated with the riginal effective date f 11/19/2012 t add the Nvitas Jurisdictin H Part B MAC Cntract Numbers 04112, 04212, 04312, and 04412 fr Clrad Part B, New Mexic Part B, Oklahma Part B, Texas Part B, Indian Health Service (IHS)/Tribal/Urban Indian Prviders Part B, and Veterans Affairs (VA) Part B. N ther changes were made t this LCD. 10/29/2012 (Revisin Histry Number 4) Per CMS Change Request (CR) 7812, this LCD has been updated with the riginal effective date f 10/29/2012 t add the Nvitas Jurisdictin H Part A MAC Cntract Numbers 04911, 04111, 04211, 04311, and 04411 fr Clrad Part A, New Mexic Part A, Oklahma Part A, Texas Part A, Indian Health Service (IHS)/Tribal/Urban Indian Prviders Part A, and Veterans Affairs (VA) Part A. N ther changes were made t this LCD. 10/22/2012 (Revisin Histry Number 3) LCD riginal effective date f 10/22/2012 fr Mississippi Part B. 08/20/2012 (Revisin Histry Number 2) LCD Original effective date f 08/20/2012 fr Arkansas Part A, Luisiana Part A, and Mississippi A. 08/13/2012 (Revisin Histry Number 1) LCD riginal effective date f 08/13/2012 fr Arkansas Part B and Luisiana Part B. LCD psted fr ntice n 06/28/2012. Reasn fr Change CMS Requirement Related Dcuments This LCD has n Related Dcuments. LCD Attachments All Versins Updated n 11/05/2012 with effective dates 11/19/2012 - N/A Updated n 10/16/2012 with effective dates 10/29/2012-11/18/2012