Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27536

Transthoracic Echocardiography (TTE)

L27536

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.

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.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Transthoracic echocardiography (TTE) is a noninvasive test that examines the size, shape, and motion of cardiac structures. The techniques most commonly used in echocardiography are M-mode (motion-mode) and two-dimensional (cross-sectional). In M-mode echocardiography, a single pencil-like ultrasound beam strikes the heart, producing an ice pick or vertical view of cardiac structures. This method is especially useful for precisely recording the motion and dimensions of intracardiac structures with respect to time. In two-dimensional echocardiography, the ultrasound beam rapidly sweeps through an arc, producing a cross-sectional or fan-shaped view of cardiac structures; this technique is useful for recording lateral motion and providing the correct spatial relationship between cardiac structures.

Covered Indications
Transthoracic echocardiography is covered for the following indications. Please note that the frequencies listed are intended only as a guideline. Frequencies exceeding these guidelines may be evaluated on an individual basis according to medical necessity.

1. Murmurs and Valvular Heart Disease

For valve disease of moderate or greater severity or with abnormal ventricular function, a routine annual follow up exam is generally indicated in the absence of significant changes in signs, symptoms or treatments. A routine annual follow up exam is seldom indicated for mild valve lesions in a stable patient with normal ventricular function.

When treatments need to be monitored or there are significant changes in signs or symptoms, a repeat TTE(s) may be performed within a year. Examination frequency is dictated by the individual clinical course. The medical record should reflect the appropriate documentation of medical necessity and be available upon request.

2. Acute Endocarditis

Examination frequency is dictated by the individual clinical course.

3. Chest Pain

Chest pain in and of itself is not an eligible condition for echocardiography studies. However, echocardiography is eligible for the condition of chest pain in the following instances:

• Diagnosis of underlying cardiac disease in patients with chest pain and clinical evidence of valvular, pericardial, or primary myocardial disease
• Chest pain in patients with severe hemodynamic instability

These should be reported with the diagnosis code for the underlying cardiac disease or severe hemodynamic instability.

Diagnosis code 786.50 (unspecified chest pain) is covered only when the echocardiography study is performed for:

• Evaluation of chest pain in patients with suspected acute myocardial ischemia, when baseline ECG is nondiagnostic and when the study can be obtained during pain or soon after its abatement.
• Evaluation of chest pain in patients with suspected aortic dissection

4. Acute Myocardial Infarction and Coronary Insufficiency

TTE is valuable in the predischarge or postdischarge assessment of the left ventricular ejection fraction and left ventricular diastolic function for prognosis and when results are used to guide therapy. Medical documentation should include this information. TTE is indicated for the evaluation of suspected complications of myocardial ischemia/infarction, including but not limited to acute MR, hypoxemia, abnormal chest X-ray, VSD, free wall rupture/tamponade, shock, right ventricular involvement, heart failure or thrombus.

5. Ventricular Function/Cardiomyopathies/Heart Failure 

In the absence of significant changes in signs, symptoms, or treatments, it is not generally medically necessary to repeat TTE more frequently than annually, unless results will guide therapy.

6. Pericardial Disease

Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually medically necessary.

7. Cardiac Tumors and Masses

Mass lesions may or may not require serial follow up studies, depending on a number of factors, including suspected diagnosis, available treatment options and propensity to remain stable, recur or cause embolic arrhythmic or hemodynamic events. A TTE may be repeated when the results will be used to guide care.

8. Diseases of The Great Vessels/Aortic Pathology

Repetition frequency should be on an individual consideration basis.

9. Pulmonary Disease

In the absence of significant changes in signs, symptoms, or treatments, it is not medically necessary to repeat more frequently than annually.

10. Arrhythmia

Payment for an echocardiographic study, for the following arrhythmias, may be allowed for the purpose of identifying structural heart disease. For this indication, normal utilization should not exceed one study per year. If more than one echocardiography study is required within a year's time, the study should be reported with the diagnosis code for the related structural heart disease.

• atrial flutter (427.32)
• atrial fibrillation (427.31)
• premature ventricular contractions (PVCs)(427.69)
• supraventricular tachycardia (427.0, 427.89)
• ventricular tachycardia (427.1)
• ventricular fibrillation (427.41)
• ventricular flutter (427.42)
• cardiac arrest (427.5)

11. Palpitation

Echocardiography performed for palpitation is covered only when there is a corresponding covered arrhythmia, cardiac sign, or symptom. This should be reported using the covered diagnosis code(s) that reflects the arrhythmia, cardiac sign, or symptom.

12. Hypertensive Cardiovascular Disease

Baseline TTE (CPT 93308) and periodic serial assessment (no more frequently than annually) would be medically appropriate. More frequent assessment should have explicit medical necessity documentation.

13. Suspected Cardiac Thrombi and Embolic Sources/Neurological Disease

TTE is recommended for an initial evaluation. Follow up TTE is indicated only when the exam would change or guide treatment. (e.g. regression or stability of potentially embolic structures/thrombus).

14. Critically Ill and Trauma Patients

Frequency is on an individual consideration basis.

15. Adult Congenital Heart Disease

When the disease process and therapy are stable, serial assessment by TTE requires medical necessity documentation if the frequency exceeds an annual evaluation. For surgically repaired simple shunt lesions (ASD, VSD, PDA) a routine annual follow up exam is not indicated in a stable patient with no associated structural or functional cardiac disease.

16. Poisoning and Injury/Exposure to Cardiotoxic Agents (Chemotherapeutic and External)

For exposure to toxic therapeutic agents, baseline assessment, bimonthly during therapy and at six (6) months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered medically reasonable and necessary.

17. Postoperative Cardiac Transplant and Rejection Monitoring

TTE is usually performed weekly for the first four to eight (4-8) weeks following transplant with decremental frequency subsequently. Absent acute rejection episodes, approximately three (3) TTE examinations are typically performed yearly in chronic transplant recipients. TTE of cardiac allografts will most appropriately be performed at transplant centers by examiners with unique expertise in the management of cardiac allograft recipients. Others will be expected to provide appropriate medical necessity documentation.

18. Prosthetic Heart Valves (Mechanical and Bio-prostheses)

Reassessment following convalescence (3-6 months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate.

Contrast Agents

Echo contrast agents will be reimbursed for echocardiography enhancement when a conventional study (echocardiogram) has failed to opacify the left ventricle. A contrast agent is considered medically necessary when it is used to improve the delineation of the left ventricular endocardial borders. This is especially applicable during the performance of exercise echocardiographic stress testing.

Coverage Limitations

Screening and/or routine interval examinations are not covered.

Examinations performed in conjunction with other diagnostic testing that provides similar information, e.g., nuclear medicine studies, MRI and CT, may be denied. The need for similar tests must be medically justified.

Diagnostic Tests and X-Rays, Outpatient Hospital Services

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.

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.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. 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.
   
3. 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.

Adequate documentation is essential for high quality patient care. There should be a permanent record of the echocardiogram and its interpretation included in the medical record. The interpretation should be a comprehensive report addressing the relevant clinical history and issues, comparative information (when available), and complete interpretive impression/findings. Images of all appropriate areas, both normal and abnormal, should be recorded. Variation from normal size should be accompanied by measurements.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Pursuant to the frequency guidelines listed in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy; excluding acute endocarditis, pericardial effusion, and postoperative cardiac transplant and rejection monitoring; it is expected that usual utilization of TTE should not exceed four (4) studies is a twelve (12) month period.

Training and Experience of Sonographers and Physicians
The accuracy of cardiac ultrasound depends on the knowledge, skill and experience of the sonographer and physician. Sonographers who perform or supervise the studies must be capable of demonstrating training and experience specific to the study performed and maintain documentation for postpayment audit. Physicians who perform, supervise, and/or interpret the studies must be capable of demonstrating training and experience specific to the study performed or interpreted and maintain documentation for postpayment audit.

The performance of this study is limited to sonographers and physicians who are highly skilled in transthoracic echocardiography. The accuracy and utility of the results are dependent on the skill of the performing provider; therefore, the provider may be subject to a post payment peer review in order to verify his/her qualifications.

A physician or a sonographer may personally perform cardiac ultrasound procedures. When a physician employs auxiliary personnel to assist him/her in rendering ultrasound procedures, the services of such personnel are considered "incident to" the physician's service. All guidelines set forth by CMS regarding "incident to" must be met.

Bedetti G, Pasanisi EM, Tintori G, et.al. Stress echo in chest pain unit: SPEED trial. Int J Cardiol. 2005; 102(3):461-7.

Chandra A, Rudraiah L, Zalenski RJ. Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001: 19(1):87-103.

Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA Guidelines for the Clinical Application of Echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography) Developed in collaboration with the American Society of Echocardiography. Circulation 1997.

Current Procedural Terminology(CPT®), copyright 2005 American Medical Association. All Rights Reserved.

Manning WJ. Transthoracic echocardiography: Normal cardiac anatomy and tomographic views. Retrieved Januariy 12, 2006, from UpToDate® at http://www.uptodate.com.

Mor-Avi V, Lang RM. Color kinesis. Retrieved Januariy 12, 2006, from UpToDate® at http://www.uptodate.com.

Sabbath A, Pack M, Markiewicz R, John J, Gaballa M, Goldman S, Thai H. Dobutamine stress echo is superior to exercise stress testing in achieving target heart rate among patients on beta blockers. Cardiology. 2005; 104(3):138-42.

Senior R, Dwivedi G, Hayat S, Lim TK. Clinical benefits of contrast-enhanced echocardiography during rest and stress examinations. Eur J Echocardiogr. 2005; 6(Suppl 2):S6-13.

Sicari R, Pasani E, Venneri L, Landi P, Cortigiani L, Picano E. Stress echo results predict mortality: a large-scale multicenter prospective international study. J Am Coll Cardiol. 2003; 41(4):589-95.

Weissman NJ. Contrast echocardiography. Retrieved Januariy 12, 2006, from UpToDate® at http://www.uptodate.com.

Weissman NJ, Schiller NB. Role of echocardiography in acute myocardial infarction. Retrieved Januariy 12, 2006, from UpToDate® at http://www.uptodate.com.

CMD Cardiology Clinical Workgroup

Other Contractor's Policies

Highmark Medicare Services Contractor Medical Directors

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 that include representatives from Cardiology.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27536

05/22/2008

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