Contractor Information
Contractor Name:
Highmark Medicare Services
Contractor Number:
12102, 12202, 12302
Contractor Type:
MAC Part A & B
LCD Information
LCD Database ID Number
L27490
LCD Title
Electrocardiography
Contractor’s Determination Number
L27490
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CMS National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Title XVIII of the Social Security Act, Section 1862 (a)(1)(D) Investigational or Experimental
CMS Manual System, Pub. 100-02 Medicare Benefit Policy Manual
CMS Manual System, Pub. 100-04 Medicare Claims Processing Manual
Primary Geographic Jurisdiction
Maryland, District of Columbia, Delaware
Oversight Region
Central Office
Original Determination Effective Date
For services performed on or after 07/11/2008
Original Determination Ending Date
N/A
Revision Effective Date
For services performed on or after N/A
Revision Ending Date
N/A
Indications and Limitations of Coverage and/or Medical Necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
A twelve lead electrocardiogram (ECG, EKG) is a recording of the electrical impulses that stimulate the heart to contract. The ECG is helpful in diagnosing and monitoring multiple clinical, anatomical and pathologic abnormalities associated with the electrical activity of the heart.
The ECG provides a continuous picture of the electrical activity during a cycle. Heart cells are charged or polarized in the resting state, but when electrically stimulated, they depolarize. When the depolarization (stimulation) process sweeps in a wave across the cells of the myocardium, the electrical current generated is conducted to the body's surface where it is detected by electrodes placed on the patient's limbs and chest. An ECG tracing shows the voltage of the waves and the time duration of both waves and intervals. By studying the amplitude and time duration of the waves and intervals, disorders of impulse formation and conduction can be diagnosed.
Electrocardiograms are indicated for the diagnosis of disorders of cardiac rhythm, anatomy, coronary blood flow, myocardial function, and symptoms related to such disorders; also, as an adjunct to the diagnosis of certain drug toxicities and metabolic disorders.
Indications
- Assessments of efficacy of antiarrhythmic therapy
- Evaluation of a patient with a pacemaker with or without clinical findings (history or physical examination) that suggest possible pacemaker malfunction
- Monitoring the effects of cardiotoxic drugs
- As an adjunct to the diagnosis of some metabolic derangements such as hyper or hypokalemia, acidosis, alkalosis
- Evaluation of a patient with known coronary artery disease (CAD) and/or heart muscle disease that presents with symptoms such as increasing dyspnea, palpitations, angina, etc.
- To evaluate the patient presenting with symptoms suggestive of a myocardial infarction (MI)
- Evaluation of other symptomatology which may indicate a cardiac origin especially in those patients who have a history of a MI, CABG surgery or PTCA; or patients who are being treated medically after a positive stress test or cardiac catheterization
- Following blunt or penetrating chest trauma
- Suspicion of congenital heart disease
- Preoperatively in a patient at risk for undiagnosed or asymptomatic heart disease or patients undergoing cardiac surgery such as CABG, AICD or pacemaker placement. The decision to perform an ECG should be determined by patient age, known risk factors for heart disease, symptoms, the surgical procedure planned, and the length of time since the patient's most recent ECG without intervening symptoms. (Medical record documentation must reflect potential risk).
- Evaluation and management of the patient with a significant cardiac arrhythmia or conduction disorder
- Systemic diseases that involve the heart
Limitations
- ECGs (like all diagnostic testing) must have relevance to a specific diagnosis and to the management of an abnormality of function of the body. Therefore, ECGs performed for other than diagnostic confirmation, disease process management or for previously defined preoperative indications will not be covered.
- Sequential ECGs, either short term for an acute condition, or long term for a chronic condition are often appropriate, but should not be done unless evolution of a pathologic process is being monitored, or a change in therapy may result from the findings. Excessively frequent ECGs, without medical record documentation to support the repeated tests as described above, will not be covered.
- Medicare generally does not cover screening for heart disease. Though performance of a baseline electrocardiogram in certain asymptomatic persons is considered by many to be appropriate and standard medical practice, Medicare, by statute, may pay for such an electrocardiogram only as part of the one-time "Welcome to Medicare", Initial Preventive Physical Examination (IPPE) afforded by section 611 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. All other electrocardiography performed on asymptomatic individuals is considered screening regardless of the presence of risk factors (for cardiac disease) such as family history, hypertension, diabetes mellitus, hyperlipidemia, or advanced age in circumstances where information obtained from the electrocardiogram does not directly affect management of the underlying disease.
- Generally, one interpretation should be paid per ECG tracing. Electrocardiogram interpretations (including"over-readings") that are not made contemporaneous to patient care, and/or that do not directly contribute to the diagnosis and treatment of the individual patient, are not covered and should not be billed to Medicare. Examples of such non-covered over-reading services include those that are performed by a physician, whether or not that physician is treating the patient, in such a manner that the interpretation is unavailable to the treating physician timely for use in decision making regarding patient care (e.g., interpretations of pre-operative tracings that are not available to the surgeon prior to the procedure and interpretations of tracings performed during an Evaluation and Management service prompted by acute symptoms that are not available until after the medical decision making is complete).
Coverage Topic
Cardiovascular Screening, Diagnostic Tests and X-rays, Outpatient Hospital Services, "Welcome to Medicare" Physical Exam
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.
11x | Hospital-inpatient (including Part A) |
12x | Hospital-inpatient or home health visits (Part B only) |
13x | Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00) |
18x | Hospital-swing beds |
21x | SNF-inpatient, Part A |
22x | SNF-inpatient or home health visits (Part B only) |
23x | SNF-outpatient (HHA-A also) |
28x | SNF-swing beds |
71x | Clinic-rural health |
73x | Clinic-independent provider based FQHC (eff 10/91) |
83x | Special facility or ASC surgery-ambulatory surgical center (Discontinued for Hospitals Subject to Outpatient PPS; hospitals must use 13X for ASC claims submitted for OPPS payment -- eff. 7/00) |
85x | Special facility or ASC surgery-rural primary care hospital (eff 10/94) |
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.
073X | EKG/ECG-general classification |
CPT/HCPCS Codes
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
93000 | ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH INTERPRETATION AND REPORT |
93005 | ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT |
93010 | ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; INTERPRETATION AND REPORT ONLY |
G0366 | ELECTROCARDIOGRAM, ROUTINE ECG WITH 12 LEADS; PERFORMED AS A COMPONENT OF THE INITIAL PREVENTIVE EXAMINATION WITH INTERPRETATION AND REPORT |
G0367 | TRACING ONLY, WITHOUT INTERPRETATION AND REPORT, PERFORMED AS A COMPONENT OF THE INITIAL PREVENTIVE EXAMINATION |
G0368 | INTERPRETATION AND REPORT ONLY, PERFORMED AS A COMPONENT OF THE INITIAL PREVENTIVE EXAMINATION |
ICD-9 Codes that Support Medical Necessity
It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.
These ICD-9-CM codes apply to CPT/HCPCS codes 93000, 93005, and 93010:
TUBERCULOSIS OF OTHER SPECIFIED ORGANS UNSPECIFIED EXAMINATION - TUBERCULOSIS OF OTHER SPECIFIED ORGANS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) | |
032.82 | DIPHTHERITIC MYOCARDITIS |
036.2 | MENINGOCOCCEMIA |
MENINGOCOCCAL CARDITIS UNSPECIFIED - MENINGOCOCCAL MYOCARDITIS | |
STREPTOCOCCAL SEPTICEMIA - UNSPECIFIED SEPTICEMIA | |
042 | HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE |
COXSACKIE CARDITIS UNSPECIFIED - COXSACKIE MYOCARDITIS | |
086.0 | CHAGAS' DISEASE WITH HEART INVOLVEMENT |
088.81 | LYME DISEASE |
ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC - CARDIOVASCULAR SYPHILIS UNSPECIFIED | |
GONOCOCCAL PERICARDITIS - OTHER GONOCOCCAL HEART DISEASE | |
112.81 | CANDIDAL ENDOCARDITIS |
HISTOPLASMA CAPSULATUM PERICARDITIS - HISTOPLASMA CAPSULATUM ENDOCARDITIS | |
HISTOPLASMA DUBOISII PERICARDITIS - HISTOPLASMA DUBOISII ENDOCARDITIS | |
HISTOPLASMOSIS PERICARDITIS UNSPECIFIED - HISTOPLASMOSIS ENDOCARDITIS | |
124 | TRICHINOSIS |
130.3 | MYOCARDITIS DUE TO TOXOPLASMOSIS |
135 | SARCOIDOSIS |
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE | |
162.9 | MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED |
MALIGNANT NEOPLASM OF THYMUS - MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED | |
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE | |
198.89 | SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
212.7 | BENIGN NEOPLASM OF HEART |
GOITER SPECIFIED AS SIMPLE - GOITER UNSPECIFIED | |
NONTOXIC UNINODULAR GOITER - UNSPECIFIED NONTOXIC NODULAR GOITER | |
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM | |
243 | CONGENITAL HYPOTHYROIDISM |
POSTSURGICAL HYPOTHYROIDISM - UNSPECIFIED ACQUIRED HYPOTHYROIDISM | |
DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED | |
PURE HYPERCHOLESTEROLEMIA - UNSPECIFIED DISORDER OF LIPOID METABOLISM | |
275.0 | DISORDERS OF IRON METABOLISM |
DISORDERS OF MAGNESIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM | |
HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED | |
AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS | |
291.0 | ALCOHOL WITHDRAWAL DELIRIUM |
292.81 | DRUG-INDUCED DELIRIUM |
293.0 | DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE |
293.1 | SUBACUTE DELIRIUM |
306.2 | CARDIOVASCULAR MALFUNCTION ARISING FROM MENTAL FACTORS |
ORGANIC SLEEP APNEA, UNSPECIFIED - OTHER ORGANIC SLEEP APNEA | |
RHEUMATIC FEVER WITHOUT HEART INVOLVEMENT - UNSPECIFIED CIRCULATORY SYSTEM DISORDER | |
506.1 | ACUTE PULMONARY EDEMA DUE TO FUMES AND VAPORS |
514 | PULMONARY CONGESTION AND HYPOSTASIS |
518.4 | ACUTE EDEMA OF LUNG UNSPECIFIED |
518.5 | PULMONARY INSUFFICIENCY FOLLOWING TRAUMA AND SURGERY |
TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) - ACUTE AND CHRONIC RESPIRATORY FAILURE | |
526.9* | UNSPECIFIED DISEASE OF THE JAWS |
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED | |
634.50 | SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY SHOCK |
635.50 | LEGALLY INDUCED ABORTION UNSPECIFIED COMPLICATED BY SHOCK |
636.50 | ILLEGAL ABORTION UNSPECIFIED COMPLICATED BY SHOCK |
637.50 | LEGALLY UNSPECIFIED TYPE OF ABORTION UNSPECIFIED COMPLICATED BY SHOCK |
638.5 | FAILED ATTEMPTED ABORTION COMPLICATED BY SHOCK |
639.5 | SHOCK FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES |
639.8 | OTHER SPECIFIED COMPLICATIONS FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES |
BENIGN ESSENTIAL HYPERTENSION COMPLICATING PREGNANCY CHILDBIRTH AND THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED POSTPARTUM HYPERTENSION | |
CONGENITAL CARDIOVASCULAR DISORDERS OF MOTHER COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER CARDIOVASCULAR DISEASES OF MOTHER POSTPARTUM | |
CARDIAC COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY UNSPECIFIED AS TO EPISODE OF CARE - CARDIAC COMPLICATIONS OF ANESTHESIA OR OTHER SEDATION IN LABOR AND DELIVERY POSTPARTUM | |
OBSTETRIC SHOCK UNSPECIFIED AS TO EPISODE OF CARE - POSTPARTUM OBSTETRIC SHOCK | |
OTHER COMPLICATIONS OF OBSTETRICAL SURGERY AND PROCEDURES UNSPECIFIED AS TO EPISODE OF CARE - OTHER COMPLICATIONS OF OBSTETRICAL SURGERY AND PROCEDURES POSTPARTUM CONDITION OR COMPLICATION | |
OBSTETRICAL AIR EMBOLISM UNSPECIFIED AS TO EPISODE OF CARE - OTHER OBSTETRICAL PULMONARY EMBOLISM POSTPARTUM | |
PERIPART CARDIOMYOPATHY UNSPECIFIED - PERIPARTUM CARDIOMYOPATHY WITH POSTPARTUM CONDITION OR COMPLICATION | |
SYSTEMIC LUPUS ERYTHEMATOSUS - UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE | |
RHEUMATOID ARTHRITIS - UNSPECIFIED INFLAMMATORY POLYARTHROPATHY | |
719.41* | PAIN IN JOINT INVOLVING SHOULDER REGION |
720.0 | ANKYLOSING SPONDYLITIS |
723.1 | CERVICALGIA |
729.1 | MYALGIA AND MYOSITIS UNSPECIFIED |
729.5* | PAIN IN LIMB |
733.6 | TIETZE'S DISEASE |
COMMON TRUNCUS - UNSPECIFIED DEFECT OF SEPTAL CLOSURE | |
CONGENITAL PULMONARY VALVE ANOMALY UNSPECIFIED - UNSPECIFIED CONGENITAL ANOMALY OF CIRCULATORY SYSTEM | |
759.3 | SITUS INVERSUS |
759.82 | MARFAN SYNDROME |
FETAL DEATH FROM ASPHYXIA OR ANOXIA BEFORE ONSET OF LABOR OR AT UNSPECIFIED TIME - UNSPECIFIED SEVERITY OF BIRTH ASPHYXIA IN LIVEBORN INFANT | |
769 | RESPIRATORY DISTRESS SYNDROME IN NEWBORN |
779.85 | CARDIAC ARREST OF NEWBORN |
COMA - PERSISTENT VEGETATIVE STATE | |
780.09* | ALTERATION OF CONSCIOUSNESS OTHER |
780.2 | SYNCOPE AND COLLAPSE |
FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS | |
780.4 | DIZZINESS AND GIDDINESS |
780.79 | OTHER MALAISE AND FATIGUE |
780.8 | GENERALIZED HYPERHIDROSIS |
781.5 | CLUBBING OF FINGERS |
782.3 | EDEMA |
782.5 | CYANOSIS |
782.61 | PALLOR |
782.62 | FLUSHING |
784.1 | THROAT PAIN |
TACHYCARDIA UNSPECIFIED - OTHER ABNORMAL HEART SOUNDS | |
SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA | |
785.9 | OTHER SYMPTOMS INVOLVING CARDIOVASCULAR SYSTEM |
RESPIRATORY ABNORMALITY UNSPECIFIED - RESPIRATORY ABNORMALITY OTHER | |
UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN | |
786.6 | SWELLING MASS OR LUMP IN CHEST |
NAUSEA WITH VOMITING - VOMITING ALONE | |
ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER SPECIFIED SITE | |
790.4 | NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH) |
793.2 | NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS |
UNSPECIFIED ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM - OTHER NONSPECIFIC ABNORMAL FUNCTION STUDY OF CARDIOVASCULAR SYSTEM | |
ASPHYXIA - HYPOXEMIA | |
799.1 | RESPIRATORY ARREST |
799.9 | OTHER UNKNOWN AND UNSPECIFIED CAUSE OF MORBIDITY OR MORTALITY |
CLOSED FRACTURE OF STERNUM - FLAIL CHEST | |
TRAUMATIC PNEUMOTHORAX WITHOUT OPEN WOUND INTO THORAX - INJURY TO MULTIPLE AND UNSPECIFIED INTRATHORACIC ORGANS WITH OPEN WOUND INTO CAVITY | |
OPEN WOUND OF CHEST (WALL) WITHOUT COMPLICATION - OPEN WOUND OF CHEST (WALL) COMPLICATED | |
INJURY TO CAROTID ARTERY UNSPECIFIED - INJURY TO UNSPECIFIED BLOOD VESSEL OF HEAD AND NECK | |
INJURY TO THORACIC AORTA - INJURY TO UNSPECIFIED BLOOD VESSEL OF THORAX | |
922.1 | CONTUSION OF CHEST WALL |
926.11 | CRUSHING INJURY OF BACK |
CRUSHING INJURY OF MULTIPLE SITES OF TRUNK - CRUSHING INJURY OF UNSPECIFIED SITE OF TRUNK | |
AIR EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA - FAT EMBOLISM AS AN EARLY COMPLICATION OF TRAUMA | |
958.4 | TRAUMATIC SHOCK |
959.11 | OTHER INJURY OF CHEST WALL |
963.1 | POISONING BY ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS |
965.09 | POISONING BY OTHER OPIATES AND RELATED NARCOTICS |
POISONING BY OXAZOLIDINE DERIVATIVES - POISONING BY OTHER AND UNSPECIFIED AGENTS PRIMARILY AFFECTING THE CARDIOVASCULAR SYSTEM | |
POISONING BY MERCURIAL DIURETICS - POISONING BY URIC ACID METABOLISM DRUGS | |
977.9 | POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE |
TOXIC EFFECT OF ETHYL ALCOHOL - TOXIC EFFECT OF UNSPECIFIED SUBSTANCE CHIEFLY NONMEDICINAL AS TO SOURCE | |
991.6 | HYPOTHERMIA |
HEAT STROKE AND SUNSTROKE - HEAT SYNCOPE | |
993.4 | EFFECTS OF AIR PRESSURE CAUSED BY EXPLOSION |
EFFECTS OF LIGHTNING - DROWNING AND NONFATAL SUBMERSION | |
ASPHYXIATION AND STRANGULATION - ELECTROCUTION AND NONFATAL EFFECTS OF ELECTRIC CURRENT | |
OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE CLASSIFIED - OTHER SPECIFIED ADVERSE EFFECTS NOT ELSEWHERE CLASSIFIED | |
MECHANICAL COMPLICATIONS OF UNSPECIFIED CARDIAC DEVICE IMPLANT AND GRAFT - OTHER MECHANICAL COMPLICATION OF CARDIAC DEVICE IMPLANT AND GRAFT | |
996.1 | MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT |
996.61 | INFECTION AND INFLAMMATORY REACTION DUE TO CARDIAC DEVICE IMPLANT AND GRAFT |
OTHER COMPLICATIONS DUE TO UNSPECIFIED DEVICE IMPLANT AND GRAFT - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN | |
CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED - RESPIRATORY COMPLICATIONS NOT ELSEWHERE CLASSIFIED | |
998.0 | POSTOPERATIVE SHOCK NOT ELSEWHERE CLASSIFIED |
999.1 | AIR EMBOLISM AS A COMPLICATION OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED |
INFECTION DUET CENTRAL VENOUS CATHETER - OTHER SERUM REACTION NOT ELSEWHERE CLASSIFIED | |
999.9 | OTHER AND UNSPECIFIED COMPLICATIONS OF MEDICAL CARE NOT ELSEWHERE CLASSIFIED |
ACCIDENT CAUSED BY EXCESSIVE HEAT DUE TO WEATHER CONDITIONS - ACCIDENTS DUE TO EXCESSIVE HEAT OF UNSPECIFIED ORIGIN | |
E901.0 | ACCIDENT DUE TO EXCESSIVE COLD DUE TO WEATHER CONDITIONS |
E901.9 | ACCIDENT DUE TO EXCESSIVE COLD OF UNSPECIFIED ORIGIN |
E924.8 | ACCIDENT CAUSED BY OTHER HOT SUBSTANCE OR OBJECT |
CARDIAC RHYTHM REGULATORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE | |
NEED FOR PROPHYLACTIC VACCINATION AND INOCULATION AGAINST INFLUENZA - NEED FOR PROPHYLACTIC VACCINATION AND INOCULATION AGAINST OTHER VIRAL DISEASES | |
PERSONAL HISTORY OF SUDDEN CARDIAC ARREST - PERSONAL HISTORY OF TRANSIENT ISCHEMIC ATTACK (TIA), AND CEREBRAL INFARCTION WITHOUT RESIDUAL DEFICITS | |
V15.1 | PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS PRESENTING HAZARDS TO HEALTH |
HEART REPLACED BY TRANSPLANT - HEART VALVE REPLACED BY TRANSPLANT | |
HEART REPLACED BY HEART ASSIST DEVICE - HEART VALVE REPLACED BY OTHER MEANS | |
UNSPECIFIED CARDIAC DEVICE IN SITU - OTHER SPECIFIED CARDIAC DEVICE IN SITU | |
POSTSURGICAL AORTOCORONARY BYPASS STATUS - PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY STATUS | |
V47.2 | OTHER CARDIORESPIRATORY PROBLEMS |
FITTING AND ADJUSTMENT OF CARDIAC PACEMAKER - FITTING AND ADJUSTMENT OF OTHER CARDIAC DEVICE | |
RADIOTHERAPY - ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION | |
LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES - LONG-TERM (CURRENT) USE OF STEROIDS | |
V58.69 | LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS |
V59.8 | DONORS OF OTHER SPECIFIED ORGAN OR TISSUE |
V71.7 | OBSERVATION FOR SUSPECTED CARDIOVASCULAR DISEASE |
PRE-OPERATIVE CARDIOVASCULAR EXAMINATION - PRE-OPERATIVE EXAMINATION UNSPECIFIED |
* Note: Use code 526.9 to report jaw pain; use code 719.41 to report shoulder pain; use code 729.5 to report left arm pain; use code 780.09 to report acute undiagnosed change in mental status.
Diagnoses that Support Medical Necessity
N/A
ICD-9 Codes that DO NOT Support Medical Necessity
All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.
General Information
Documentation Requirements
- All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
- The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.
- Documentation to support the medical necessity of the service as well as the frequency for which the services are being performed must be reflected in the patient's record. Documentation may include history and physical, progress notes with presenting symptoms, laboratory/diagnostic test results, and active treatment protocol. Office/progress notes must contain the date of service and the physician's signature.
- An ECG with interpretation must have the full graphic tracings with formal written interpretation on file for review. The interpretation should appear on the designated sections of a page formatted ECG or written in the clinical records. At a minimum, interpretations should include appropriate comments on rhythm, rate, axis, acute or chronic changes, and a comparison with the most recent tracing (if available). Appropriate measurements must be mentioned if the purpose of repeated ECGs is to monitor the effects of a given parameter, e.g., the QT interval. ECGs that are electronically read must be over-read, corrected and signed.
- A physician's order must be documented in the medical record requesting ECG performance.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Other Contractor’s Policies
Highmark Medicare Services Contractor Medical Directors
Advisory Committee Meeting Notes
This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).
CAC/IAC Distribution: 04/01/2008
Start Date of Comment Period
End Date of Comment Period:
05/15/2008
Start Date of Notice Period
05/23/2008
Revision History
Revision History Number
L27490
Revision History Explanation
| Date | Policy # | Description |
|---|---|---|
05/23/2008 |
L27490 |
Original LCD posted for notice. LCD to become effective 07/11/2008 for Maryland Part B, DCMA Part B and Delaware Part B. |
04/01/2008 |
Draft J12-D18 |
Original LCD posted for comment. |
Last Reviewed On
05/22/2008
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