Electrocardiograms Policy Number: PG0478 ADVANTAGE | ELITE | HMO Last Review: 12/07/2020
INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO
GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder contract. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This guideline is solely for explaining correct procedure reporting and does not imply coverage and reimbursement.
SCOPE X Professional Excluding place-of-service 02-telehealth (because it does not distinguish between inpatient or outpatient), 15-mobile unit, 20-urgent care, 21-inpatient hospital, 23-emergency room, 24-ambulatory surgical center, 25-birthing center, 26-military treatment facility, 31-skilled nursing facility, 34-hospice, 41-ambulance-land, 42-ambulance-air or water, 51-inpatient psychiatric facility, 61-comprehensive inpatient rehabilitation facility, 65-end-stage renal disease treatment facility. _ Facility
DESCRIPTION An electrocardiogram (EKG/ECG) is a non-invasive test that measures and records the electrical activity of the heart. By positioning the electrical sensing devices, leads, on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG/ECG. EKG/ECG services are diagnostic tests utilized when there are documented signs and symptoms or other clinical indications for providing the service. The recording is reviewed by a physician who provides an interpretation and written report. An EKG/ECG may be reported as the technical aspect only, the interpretation and written report only, or both aspects together as one service.
Guidelines from the U.S. Preventive Services Task Force (USPSTF) (2011), the American Academy of Family Physicians (AAFP) (2011), the American College of Cardiology (ACC) Foundation (2010), and the American Heart Association (AHA) (2010) advise against electrography in asymptomatic, low-risk individuals. There is little evidence that detection of coronary artery stenosis in asymptomatic patients at low-risk for coronary heart disease improves health outcomes. False-positive tests are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit
POLICY Effective 9/1/2020 EKG/ECG services should not routinely be performed as part of a preventive exam unless the member has signs and symptoms of coronary heart disease, family history or other clinical indications at the visit that would justify the test.
Office/Outpatient Electrocardiograms, 93000, 93005, 93010, 93040, 93041, 93042, do not require a prior authorization, however, must meet the ICD-10 medically indication, as listed below, for coverage.
PG0478 – 12/07/2020 COVERAGE CRITERIA HMO, PPO, Individual Marketplace, Elite/ProMedica Medicare Plan, Advantage An EKG/ECG is indicated to diagnose or treat a patient for symptoms, signs, or a history of heart disease; or systemic conditions that affect the heart, including: Chest pain or angina pectoris, Myocardial ischemia or infarction, Arteriovascular disease including coronary, central, and peripheral disease, Hypertension, Conduction abnormalities, Cardiac rhythm disturbances, Cardiac hypertrophy, Heart failure, Pericarditis, Structural cardiac conditions, Endocrine abnormalities, Neurological disorders affecting the heart, Syncope, Paroxysmal weakness, Palpitations, Sudden lightheadedness, Electrolyte imbalance, Acid-base disorders, Temperature disorders, Pulmonary disorders, and Drug cardiotoxicity.
An EKG/ECG may help identify cardiac disorders as part of a preoperative clinical evaluation. A preoperative EKG/ECG may be reasonable and necessary under one of the following conditions: In the presence of pre-existing heart disease such as congestive heart failure, prior myocardial infarction (MI), angina, coronary artery disease, or dysrhythmias; In the presence of known comorbid conditions that may affect the heart, such as chronic pulmonary disease, peripheral vascular disease, diabetes, or renal impairment; or When the pending surgery requires a general or regional anesthetic.
Coding Guidelines: The results of the EKG/ECG must be relevant to the management of the patient. Payment will not be paid twice for a service that is required only once to diagnose or treat and illness or injury. A second payment may be warranted when an additional physician expertise is necessary and reasonable to diagnose or treat the patient, such as to clarify a questionable finding. The second physician’s knowledge and expertise must be significantly greater than that of the first reader, and it must contribute substantially to the interpretation. Routine second readings are not reimbursed. And/or a second EKG/ECG is needed to determine a cardiac change. When billing subsequent electrocardiograms on the same day, use modifier 76 if repeated by the same provider or modifier 77 when repeated by a different provider. When an EKG/ECG is performed on the same day as a cardiac stress test, but is not part of that stress test, it is separately payable. The EKG/ECG must add additional information to the stress test. For example, an EKG/ECG may be reasonable and necessary to rule out an acute MI prior to a same day stress EKG/ECG performed to evaluate possible accelerating angina. Typically, when the EKG/ECG stress test is scheduled in advance, a separate EKG/ECG on the same day is not reasonable and necessary. An EKG/ECG is not a covered benefit when used for screening purposes or as part of a routine physical examination. Routine physical examinations (screening) are evaluation and management services supplied in the absence of associated signs, symptoms or complaints. A second EKG/ECG performed to replace a technically inadequate EKG/ECG may not be reported as an additional service.
PG0478 – 12/07/2020 Rhythm EKG/ECGs are used to evaluate signs and symptoms that may reflect a cardiac rhythm disorder. A rhythm EKG/ECG interpretation and report only (93042) is included in a 12-lead EKG/ECG interpretation and report (93000 or 93010). A rhythm EKG/ECG tracing (93040 or 93041) is included in a 12-lead EKG/ECG tracing (93000 or 93005). When several EKG/ECG rhythm (or monitor) strips from a single date of service are reviewed at a single setting, report only one unit of service, regardless of the number of strips reviewed. If one physician bills a rhythm strip interpretation, and another physician bills an EKG/ECG interpretation for the same patient on the same date of service, then both services must be reasonable and necessary. Typically, the patient will receive and require prolonged rhythm monitoring in addition to a 12-lead EKG/ECG. An EKG/ECG furnished on an emergency basis by a laboratory or a portable X-ray supplier requires that a physician be in attendance at the time the service was performed or immediately thereafter. Payments for a home-based EKG/ECG above the EKG/ECG base amount (i.e., for transportation costs) requires a medical need for performing the service in the patient's home, in addition to the need for the EKG/ECG itself. Typically, qualifying patients will be homebound or bed-confined. Professional payment for the technical component of an EKG/ECG will be denied when the facility is paid for the technical component. Patients presenting with an acute ischemic episode may require several EKG/ECGs on one or more days to delineate the severity and progression of that episode when needed to properly treat the patient. Unstable patients (e.g., electrolyte imbalance, recurrent rhythm disturbances, recurrent chest pain) may require more than one EKG/ECG annually to diagnose the condition or assess response to treatment.
Documentation Guidelines: Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request. The entire documentation – not just the test report or the finding/diagnosis on the order – must be available for review in order to establish medical reasonableness and necessity criteria. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. An interpretation and report must address the findings and comparative data, if available (i.e., a prior EKG/ECG). The patient’s medical record must be legible and clearly indicate the reasonableness and necessity of the service. The documentation must show that the service was reasonable and necessary; the test must be appropriate and medically necessary at the time and point at which it is being performed in the course of the patient’s evaluation. A laboratory or a portable X-ray supplier that supplies an EKG/ECG must maintain in its records the referring physician’s written order and the identity of the employee taking the tracing. Patients presenting with an acute ischemic episode may require several EKG/ECGs on one or more days to delineate the severity and progression of that episode when needed to properly treat the patient. Unstable patients (e.g., electrolyte imbalance, recurrent rhythm disturbances, recurrent chest pain) may require more than one EKG/ECG annually to diagnose the condition or assess response to treatment. Typically, patients with chronic stable heart disease, or other diseases potentially affecting the heart do not require an EKG/ECG.
Non-Covered Computerized 2-lead resting electrocardiogram (EKG/ECG) analysis (e.g., multifunction cardiogram) is considered investigational for diagnosing coronary artery disease (CAD). (Computerized 2-lead resting electrocardiogram analysis (e.g., multifunction cardiogram) is a computerized assessment of a 2-lead resting electrical activity of the heart. It has been proposed for use as a diagnostic test for coronary artery disease (CAD)).(0206T)
Signal-averaged electrocardiography (SAECG) is considered experimental or investigational for all indications. The evidence is insufficient to determine the effects of the technology on health outcomes. (93278)
PG0478 – 12/07/2020
Body surface potential mapping (also known as body surface mapping) is considered experimental and investigational for the following indications (not an all-inclusive list): (it has been suggested that the 12-lead EKG/ECG may not be optimal in the diagnostic assessment of acute coronary syndromes such as acute cardiac ischemia and myocardial infarction (MI) since the coverage of the standard pre-cordial leads over the thorax is limited. Some researchers have attempted to address this problem via the use of additional leads or body surface potential mapping (BSPM), also known as body surface mapping.) o Evaluation of acute coronary syndromes (e.g., acute cardiac ischemia and myocardial infarction) o Evaluation of atrial fibrillation o Evaluation of Brugada syndrome o Guidance of atrial fibrillation ablation o Prediction of response in cardiac resynchronization therapy
Microvolt T‐wave alternans (MTWA) diagnostic testing using the spectral analytic method is considered medically necessary for the evaluation of persons at risk of sudden cardiac death who meet criteria for implantable cardioverter‐defibrillator placement. The term alternans applies to conditions characterized by the sudden appearance of a periodic beat‐to‐beat change in some aspect of cardiac electrical or mechanical behavior. Microvolt T‐wave alternans testing is performed by placing high‐ resolution electrodes, designed to reduce electrical interference, on a patient’s chest prior to a period of controlled exercise. MTWA diagnostic testing using the spectral analytic method is considered experimental and investigational for all other indications. (93025)
CODING/BILLING INFORMATION The appearance of a code in this section does not necessarily indicate coverage. Codes that are covered may have selection criteria that must be met. Payment for supplies may be included in payment for other services rendered. 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 93040 Rhythm ECG, 1-3 leads; with interpretation and report 93041 Rhythm ECG, 1-3 leads; tracing only without interpretation and report 93042 Rhythm ECG, 1-3 leads; interpretation and report only Related Non-Covered Procedures 93025 Microvolt T‐wave alternans for assessment of ventricular arrhythmias[not covered for the diagnosis and risk assessment of acute coronary syndrome and guiding anti‐arrhythmic therapy] 93278 Signal-averaged electrocardiography (SAECG), with or without ECG (Investigational/Non-Covered) 0206T Computerized database analysis of multiple cycles of digitized cardiac electrical data from two or more ECG leads, including transmission to a remote center, application of multiple nonlinear mathematical transformations, with coronary artery obstruction severity assessment. (Investigational/Non-Covered) ICD-10-CM CODES D151 BENIGN NEOPLASM OF HEART D860 SARCOIDOSIS OF LUNG D86.85 SARCOID MYOCARDITIS E0500 THYROTOXICOS DIFFUS GOITER W/O THYROTOXIC CRISIS E0501 THYROTOXICOS DIFFUS GOITER THYROTOX CRISIS/STORM E0510 THYROTOXICOSIS WITH TOXIC SINGLE THYROID NODULE WITHOUT THYROTOXIC CRISIS OR STORM E0511 THYROTOXICOSIS WITH TOXIC SINGLE THYROID NODULE WITH THYROTOXIC CRISIS OR STORM E0520 THYROTOXICOSIS WITH TOXICMULTINODULAR GOITER WITHOUT THYROTOXIC CRISIS OR STORM E0521 THYROTOXICOSIS WITH TOXICMULTINODULAR GOITER WITH THYROTOXIC CRISIS OR STORM E0530 THYROTOXICOSIS WITH ECTOPIC THYROID TISSUE WITHOUT THYROTOXIC CRISIS OR STORM E0531 THYROTOXICOSIS WITH ECTOPIC THYROID TISSUE WITH THYROTOXIC CRISIS OR STORM E0540 THYROTOXICOSIS FACTITIA WITHOUT THYROTIXIC CRISIS OR STORM E0541 THYROTOXICOSIS FACTITIA WITH THYROTIXIC CRISIS OR STORM E0580 OTHER THYROTOXICOSIS WITHOUT THYROTOXIC CRISIS OR STORM
PG0478 – 12/07/2020 E0581 OTHER THYROTOXICOSIS WITH THYROTOXIC CRISIS OR STORM E0590 THYROTOXICOSIS UNS W/O THYROTOXIC CRISIS/STORM E0591 THYROTOXICOSIS UNS W THYROTOXIC CRISIS/STORM E0789 OTHER SPECIFIED DISORDERS OF THYROID E079 DISORDER OF THYROID UNSPECIFIED E872 ACIDOSIS E873 ALKALOSIS E874 MIXED DISORDER OF ACID-BASE BALANCE E875 HYPERKALEMIA F10221 ALCOHOL DEPENDENCE WITH INTOXICATION DELIRIUM F10231 ALCOHOL DEPENDENCE WITH WITHDRAWAL DELIRIUM G458 VERTEBRO-BASILAR ARTERY SYNDROME G451 CAROTID ARTERY SYNDROME (HEMISPHERIC) G452 MULTIPLE AND BILATERAL PRECEREBRAL ARTERY SYNDROMES G453 AMAUROSIS FUGAX G454 TRANSIENT GLOBAL AMNESIA G458 OTHER TRANSIENT CEREBRAL ISCHEMIC ATTACKS AND RELATED SYNDROMES G459 TRANSIENT CEREBRAL ISCHEMIC ATTACK UNSPECIFIED G9341 METABOLIC ENCEPHALOPATHY I050 RHEUMATIC MITRAL STENOSIS I051 RHEUMATIC MITRAL INSUFFICIENCY I052 RHEUMATIC MITRAL STENOSIS WITH INSUFFICIENCY I058 OTHER RHEUMATIC MITRAL VALVE DISEASES I059 RHEUMATIC MITRAL VALVE DISEASE, UNSPECIFIED I060 RHEUMATIC AORTIC STENOSIS I061 RHEUMATIC AORTIC INSUFFICIENCY I062 RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY I068 OTHER RHEUMATIC AORTIC VALVE DISEASES I069 RHEUMATIC AORTIC VALVE DISEASE, UNSPECIFIED I070 RHEUMATIC TRICUSPID STENOSIS I071 RHEUMATIC TRICUSPID INSUFFICIENCY I072 RHEUMATIC TRICUSPID STENOSID AND INSUFFICIENCY I078 OTHER RHEUMATIC TRICUSPID VALVE DISEASES I079 RHEUMATIC TRICUSPID VALVE DISEASE, UNSPECIFIED I080 RHEUMATIC DISORDERS FOR BOTH MITRAL AND AORTIC VALVES I081 RHEUMATIC DISORDERS FOR BOTH MITRAL AND TRICUSPID VALVES I082 RHEUMATIC DISORDERS FOR BOTH AORTIC AND TRICUSPID VALVES I083 COMBINED RHEUMATIC DISORDERS OF MITRAL, AORTIC AND TRICUSPID VALVES I088 OTHER RHEUMATIC MULTIPLE VALVE DISEASES I089 RHEUMATIC MULTIPLE VALVE DISEASE, UNSPECIFIED I090 RHEUMATIC MYOCARDITIS I091 RHEUMATIC DISEASES OF ENDOCARDIUM, VALVE UNSPECIFIED I092 CHRONIC RHEUMATIC PERICARDITIS I0981 RHEUMATIC HEART FAILURE I0989 OTHER SPECIFIED RHEUMATIC HEART DISEASES I099 RHEUMATICE HEART DISEASE, UNSPECIFIED I10 ESSENTIAL PRIMARY HYPERTENSION I110 HYPERTENSIVE HEART DISEASE WITH HEART FAILURE I119 HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE I120 HYPERTENSIVE CKD W/STAGE 5 CKD OR ESRD I129 HYPERTENSIVE CKD W/STAGE 1-4 CKD OR UNS CKD I130 HTN HEART & CKD W/HF & CKD STAGE 1-4 OR UNS CKD
PG0478 – 12/07/2020 I1310 HTN HEART & CKD W/O HF W/STAGE 1-4 CKD/UNS CKD I1311 HTN HEART & CKD W/O HF W/STAGE 5 CKD OR ESRD I132 HTN HEART & CKD W/HF W/STAGE 5 CKD OR ESRD I150 RENOVASCULAR HYPERTENSION I151 HYPERTENSION SECONDARY TO OTHER RENAL DISORDERS I152 HYPERTENSION SECONDARY TO ENDOCRINE DISORDERS I158 OTHER SECONDARY HYPERTENSION I159 SECONDARY HYPERTENSION UNSPECIFIED I160 HYPERTENSIVE URGENCY I161 HYPERTENSIVE EMERGENCY I169 HYPERTENSIVE CRISIS UNSPECIFIED I200 UNSTABLE ANGINA I201 ANGINA PECTORIS WITH DOCUMENTED SPASM I208 OTHER FORMS OF ANGINA PECTORIS I209 ANGINA PECTORIS UNSPECIFIED I2102 ST ELEVATION (STEM) MYOCARDIAL INFARCTION INVOLVING LEFT MAIN CORONARY ARTERY I2102 ST ELEVATION (STEM) MYOCARDIAL INFARCTION INVOLVING LEFT ANTERIOR DESCENDING CORONARY ARTERY I2109 ST ELEVATION MI INVOLV OTH CORONARY ART ANT WALL I2111 ST ELEVATION MYOCARDIAL INFARCTION INVOLVING RCA I2119 ST ELEVATION MI INVOLV OTH CORONARY ART INF WALL I2121 ST ELEVATION (STEM) MYOCARDIAL INFARCTION INVOLVING LEFT CIRCUMFLEX CORONARY ARTERY I2129 ST ELEVATION MYOCARDIAL INFARCT INVOLV OTH SITES I213 ST ELEVATION MYOCARDIAL INFARCTION UNS SITE I214 NON-ST ELEVATION MYOCARDIAL INFARCTION I219 ACUTE MYOCARDIAL INFARCTION UNSPECIFIED I21A1 MYOCARDIAL INFARCTION TYPE 2 I21A9 OTHER MYOCARDIAL INFARCTION TYPE I220 SUBSEQUENT ST ELEVATION MYOCARD INFARCT ANT WALL I221 SUBSEQUENT ST ELEVATION MYOCARD INFARCT INF WALL I222 SUBSEQUENT NON-ST ELEVATION (NSTEM) MYOCARDIAL INFARCTION I228 SUBSEQUENT ST ELEV MYOCARDIAL INFARCT OTH SITES I229 SUBSEQUENT ST ELEVATION (STEM) MYOCARDIAL INFARCTION OF UNSPECIFIED SITE I230 HEMOPERICARDIUM AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I231 ATRIAL SEPTAL DEFECT AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I232 VENTRICUALR SEPTAL DEFECT AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I233 RUPTURE OF CARDIAC WALL WITHOUT HEMOPERICARDIUM AS CURRENT COMPLICATIN FOLLOWING ACUTE MYOCARDIAL INFARCTION I234 RUPTURE OF CHORDAE TENDINEAE AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I235 RUPTURE OF PAPILLARY MUSCLE AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I236 THROMBOSIS OF ATRIUM, AURICULAR APPENDAGE AND VENTRICLE AS CURRENT COMPLICATION FOLLOWING ACUTE MYOCARDIAL INFARCTION I237 POSTINFARCTION ANGINA I238 OTHER CURRENT COMPLICATIONS FOLLOWING ACUTE MYOCARDIAL INFARCTION I240 ACUTE CORONARY THROMBOSIS NOT RESULTING IN MYOCARDIAL INFARCTIN I241 DRESSLER’S SYNDROME I248 OTHER FORMS OF ACUTE ISCHEMIC HEART DISEASE I249 ACUTE ISCHEMIC HEART DISEASE UNSPECIFIED I2510 ASHD NATIVE CORONARY ARTERY W/O ANGINA PECTORIS I25110 ASHD NATIVE COR ART W/UNSTABLE ANGINA PECTORIS I25111 ASHD NATIVE COR ART W/ANGINA PECTORIS DOC SPASM I25118 ASHD NATIVE COR ART W/OTH FORMS ANGINA PECTORIS
PG0478 – 12/07/2020 I25119 ASHD NATIVE COR ARTREY W/UNS ANGINA PECTORIS I252 OLD MYOCARDIAL INFARCTION I253 ANEURYSM OF HEART I2541 CORONARY ARTERY ANEURYSM I2542 CORONARY ARTERY DESSECTION I255 ISCHEMIC CARDIOMYOPATHY I256 SILENT MYOCARDIAL ISCHEMIA I25700 ATHEROSCLEROSIS CABG UNS UNSTABL ANGINA PECTORIS I25701 ATHEROSCLEROSIS OF CORONARY ARTERY BYPASS GRAFT(S), UNSPECIFIED, WITH ANGINA PECTORIS WITH DOCUEMENTED SPASM I25708 ATHEROSCLEROSIS OF CORONARY ARTERY BYPASS GRAFT(S), UNSPECIFIED, WITH OTHER FORMS OF ANGINA PECTORIS I25709 ATHEROSCLEROSIS OF CORONARY ARTERY BYPASS GRAFT(S) UNSPECIFIED, WITH UNSPECIFIED ANGINA PECTORIS I25710 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS I25711 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN CORONARY ARTERY BYPASS GRAFT(S) WITH ANGINA PECTORIS WITH DOCUMENTED SPASM I25718 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN CORONARY ARTERY BYPASS GRAFT(S) WITH OTHER FORMS OF ANGINA PECTORIS I25719 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN CORONARY ARTERY BYPASS GRAFT(S) WITH UNSPECIFIED ANGINA PECTORIS I25720 ATHEROSCLEROSIS OF AUTOLOGOUS ARTERY CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA I25721 ATHEROSCLEROSIS OF AUTOLOGOUS ARTERY CORONARY ARTERY BYPASS GRAFT(S) WITH ANGINA PECTORIS WITH DOCUMENTED SPASM I25728 ATHEROSCLEROSIS OF AUTOLOGOUS ARTERY CORONARY ARTERY BYPASS GRAFT(S) WITH OTHER FORMS OF ANGINA PECTORIS I25729 ATHEROSCLEROSIS OF AUTOLOGOUS ARTERY CORONARY ARTERY BYPASS GRAFT(S) WITH UNSPECIFIED ANGINA PECTORIS I25731 ARTHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL CORONARY ARTERY BYPASS GRAFT(S) WITH ANGINA PECTORIS WITH DOCUMENTED SPASM I25738 ARTHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL CORONARY ARTERY BYPASS GRAFT(S) WITH OTHER FORMS OF ANGINA PECTORIS I25739 ARTHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL CORONARY ARTERY BYPASS GRAFT(S) WITH UNSPECIFIED ANGINA PECTORIS I25750 ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSTABLE ANGINA I25751 ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART WITH DOCUMENTED SPASM I25758 ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART WITH OTHER FORMS OF ANGINA PECTORIS I25759 ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSPECIFIED ANGINA PECTORIS I25760 ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSTABLE ANGINA I25761 ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEART WITH ANGINA PECTORIS WITH DOCUMENTED SPASM I25768 ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEART WITH OTHER FORMS OF ANGINA PECTORIS I25769 ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEART WITH UNSPECIFIED ANGINA PECTORIS I25790 ATHEROSCLEROSIS OF OTHER CORONARY ARTERY BYPASS GRAFT(S) WITH UNSTABLE ANGINA PECTORIS I25791 ATHEROSCLEROSIS OF OTHER CORONARY ARTERY BYPASS GRAFT(S) WITH ANGINA PECTORIS WITH DOCUMENTED SPASM I25798 ATHEROSCLEROSIS OF OTHER CORONARY ARTERY BYPASS GRAFT(S) WITH OTHER FORMS OF ANGINA PECTORIS I25799 ATHEROSCLEROSIS OF OTHER CORONARY ARTERY BYPASS GRAFT(S) WITH UNSPECIFIED ANGINA PECTORIS I25810 ATHEROSCLEROSIS CABG WITHOUT ANGINA PECTORIS I25811 ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OF TRANSPLANTED HEAR WITHOUT ANGINA PECTORIS
PG0478 – 12/07/2020 I25812 ATHEROSCLEROSIS OF BYPASS GRAFT OF CORONARY ARTERY OF TRANSPLANTED HEAR WITHOUT ANGINA PECTORIS I2582 CHRONIC TOTAL OCCLUSION OF CORONARY ARTERY I2583 CORONARY ATHEROSCLEROSIS DUE TO LIPID RICH PLAQUE I2584 COR ATHEROSCLER D/T CALCIFIED CORONARY LESION I2589 OTHER FORMS OF CHRONIC ISCHEMIC HEART DISEASE I259 CHRONIC ISCHEMIC HEART DISEASE UNSPECIFIED I2601 SEPTIC PULMONARY EMBOLISM WITH ACUTE COR PULMONALE I2602 SADDLE EMBOLUS PULM ART W/ACUTE COR PULMONALE I2609 OTHER PULMONARY EMBOLISM W/ACUTE COR PULMONALE I2690 SEPTIC PULMONARY EMBO W/O ACUTE COR PULMONALE I2692 SADDLE EMBOLUS OF PULMONARY ARTERY I2693 SINGLE SUBSEGMENTAL PULMONARY EMBOLISM WITHOUT ACUTE COR PULMONALE I2694 MULTIPLE SUBSEGMENTAL PULMONARY EMBOLI WITHOUT ACUTE COR PULMONALE I2699 OTH PULMONARY EMBOLISM W/O ACUTE COR PULMONALE I270 PRIMARY PULMONARY HYPERTENSION I271 KYPHOSCOLIOTIC HEART DISEASE I2720 PULMONARY HYPERTENSION UNSPECIFIED I2721 SECONDARY PULMONARY ARTERIAL HYPERTENSION I2722 PULMONARY HYPERTENSION DUE TO LEFT HEART DISEASE I2723 PULMONARY HYPERTENSION DUE TO LUNG DISEASES AND HYPOXIA I2724 CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION I2729 OTHER SECONDARY PULMONARY HYPERTENSION I2781 COR PULMONALE (CHRONIC) I2782 CHRONIC PULMONARY EMBOLISM I2783 EISENMENGER’S SYNDROME I2789 OTHER SPECIFIED PULMONARY HEART DISEASES I279 PULMONARY HEART DISEASE, UNSPECIFIED I280 ARTERIOVENOUS FISTUAL OF PULMONARY VESSELS I281 ANEURYSM OF PULMONARY ARTERY I288 OTHER DISEASES OF PULMONARY VESSELS I289 DISEASE OF PULMONARY VESSELS, UNSPECIFIED I300 ACUTE NONSPECIFIC IDIOPATHIC PERICARDITID I301 INFECTIVE PERICARDITIS I308 OTHER FORMS OF ACUTE PERICARDITIS I309 ACUTE PERICARDITIS UNSPECIFIED I310 CHRONIC ADHESIVE PERICARDITIS I311 CHRONIC CONSTRICTIVE PERICARDITIS I312 HEMOPERICARDIUM, NOT ELSEWHERE CLASSIFIED I313 PERICARDIAL EFFUSION NONINFLAMMATORY I314 CARDIAC TAMPONADE I318 OTHER SPECIFIED DISEASES OF PERICARDIUM I319 DISEASE OF PERICARDIUM UNSPECIFIED I32 PERICARDITIS IN DISEASES CLASSIFIED ELSEWHERE I330 ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS I339 ACUTE AND SUBACUTE ENDOCARDITIS, UNSPECIFIED I340 NONRHEUMATIC MITRAL VALVE INSUFFICIENCY I341 NONRHEUMATIC MITRAL VALVE PROLAPSE I342 NONRHEUMATIC MITRAL VALVE STENOSIS I348 OTHER NONRHEUMATIC MITRAL VALVE DISORDERS I349 NONRHEUMATIC MITRAL VALVE DISORDER, UNSPECIFIED I350 NONRHEUMATIC AORTIC VALVE STENOSIS I351 NONRHEUMATIC AORTIC VALVE INSUFFICIENCY
PG0478 – 12/07/2020 I352 NONRHEUMATIC AORTIC VALVE STENOSIS W/INSUFF I358 OTHER NONRHEUMATIC AORTIC VALVE DISORDER I359 NONRHEUMATIC AORTIC VALVE DISORDER, UNSPECIFIED I360 NONRHEUMATIC TRICUSPID (VALVE) STENOSIS I361 NONRHEUMATIC TRICUSPID VALVE INSUFFICIENCY I362 NONRHEUMATIC TRICUSPID STENOSIS W/INSUFFICIENCY I368 OTHER NONRHEUMATIC TRICUSPID VALVE DISORDERS I369 NONRHEUMATIC TRICUSPID VALVE DISORDER, UNSPECIFIED I370 NONRHEUMATIC PULMONARY VALVE STENOSIS I371 NONRHEUMATIC PULMONARY VALVE INSUFFICIENCY I372 NONRHEUMATIC PULMONARY VALVE STENOSIS WITH INSUFFICIENCY I378 OTHER NONRHEUMATIC PULMONARY VALVE DISORDER I379 NONRHEUMATIC PULMONARY VALVE DISORDER, UNSPECIFIED I38 ENDOCARDITIS VALVE UNSPECIFIED I39 ENDOCARDITIS AND HEART VALVE DISORDERS IN KISEASES CLASSIFIED ELSEWHERE I400 INFECTIVE MYOCARDITIS I401 ISOLATED MYOCARDITIS I408 OTHER ACUTE MYOCARDITIS I409 ACUTE MYOCARDITIS UNSPECIFIED I41 MOCARDITIES IN DISEASES CLASSIFIED ELSEWHERE I420 DILATED CARDIOMYOPATHY I421 OBSTRUCTIVE HYPERTROPHIC CARDIOMYOPATHY I422 OTHER HYPERTROPHIC CARDIOMYOPATHY I423 ENDOMYOCARDIAL (EOSINOPHILIC) DISEASE I424 ENDOCARDIAL FIBROELASTOSIS I425 OTHER RESTRICTIVE CARDIOMYOPATHY I426 ALCOHOLIC CARDIOMYOPATHY I427 CARDIOMYOPATHY DUE TO DRUG AND EXTERNAL AGENT I428 OTHER CARDIOMYOPATHIES I429 CARDIOMYOPATHY UNSPECIFIED I43 CARDIOMYOPATHY IN DISEASES CLASSIFIED ELSEWHERE I440 ATRIOVENTRICULAR BLOCK FIRST DEGREE I441 ATRIOVENTRICULAR BLOCK SECOND DEGREE I442 ATRIOVENTRICULAR BLOCK COMPLETE I4430 UNSPECIFIED ATRIOVENTRICULAR BLOCK I4439 OTHER ATRIOVENTRICULAR BLOCK I444 LEFT ANTERIOR FASCICULAR BLOCK I445 LEFT POSTERIOR FASCICULAR BLOCK I4460 UNSPECIFIED FASCICULAR BLOCK I4469 OTHER FASCICULAR BLOCK I447 LEFT BUNDLE-BRANCH BLOCK UNSPECIFIED I450 RIGHT FASCICULAR BLOCK I4510 UNSPECIFIED RIGHT BUNDLE-BRANCH BLOCK I4519 OTHER RIGHT BUNDLE-BRANCH BLOCK I452 BIFASCICULAR BLOCK I453 TRIFASCICULAR BLOCK I454 NONSPECIFIC INTRAVENTRICULAR BLOCK I455 OTHER SPECIFIED HEART BLOCK I456 PRE-EXCITATION SYNDROME I4581 LONG QT SYNDROME I4589 OTHER SPECIFIED CONDUCTION DISORDERS I459 CONDUCTION DISORDER UNSPECIFIED
PG0478 – 12/07/2020 I462 CARDIAC ARREST DUE UNDERLYING CARDIAC CONDITION I468 CARDIAC ARREST DUE TO OTHER UNDERLYING CONDITION I469 CARDIAC ARREST CAUSE UNSPECIFIED I470 RE-ENTRY VENTRICULAR ARRHYTHMIA I471 SUPRAVENTRICULAR TACHYCARDIA I472 VENTRICULAR TACHYCARDIA I479 PAROXYSMAL TACHYCARDIA UNSPECIFIED I480 PAROXYSMAL ATRIAL FIBRILLATION I4811 LONGSTANDING PERSISTENT ATRIAL FIBRILLATION I4819 OTHER PERSISTENT ATRIAL FIBRILLATION I4820 CHRONIC ATRIAL FIBRILLATION, UNSPECIFIED I4821 PERMANENT ATRIAL FIBRILLATION I483 TYPICAL ATRIAL FLUTTER I484 ATYPICAL ATRIAL FLUTTER I4891 UNSPECIFIED ATRIAL FIBRILLATION I4892 UNSPECIFIED ATRIAL FLUTTER I4901 VENTRICULAR FIBRILLATION I4902 VENTRICULAR FLUTTER I491 ATRIAL PREMATURE DEPOLARIZATION I492 JUNCTIONAL PREMATURE DEPOLARIZATION I493 VENTRICULAR PREMATURE DEPOLARIZATION I4940 UNSPECIFIED PREMATURE DEPOLARIZATION I4949 OTHER PREMATURE DEPOLARIZATION I495 SICK SINUS SYNDROME I498 OTHER SPECIFIED CARDIAC ARRHYTHMIAS I499 CARDIAC ARRHYTHMIA UNSPECIFIED I501 LEFT VENTRICULAR FAILURE I5020 UNSPECIFIED SYSTOLIC CONGESTIVE HEART FAILURE I5021 ACUTE SYSTOLIC CONGESTIVE HEART FAILURE I5022 CHRONIC SYSTOLIC CONGESTIVE HEART FAILURE I5023 ACUTE CHRON SYSTOLIC HEART FAILURE I5030 UNSPECIFIED DIASTOLIC CONGESTIVE HEART FAILURE I5031 ACUTE DIASTOLIC CONGESTIVE HEART FAILURE I5032 CHRONIC DIASTOLIC CONGESTIVE HEART FAILURE I5033 ACUTE ON CHRON DIASTOLIC CONGESTIV HEART FAILURE I5040 UNSPECIFIED COMBINED SYSTOLIC & DIASTOLIC CHF I5041 ACUTE COMBINED SYSTOLIC AND DIASTOLIC CHF I5042 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC CHF I5043 ACUTE ON CHRONIC COMB SYSTOLIC & DIASTOLIC CHF I50810 RIGHT HEART FAILURE UNSPECIFIED I50811 ACUTE RIGHT HEART FAILURE I50812 CHRONIC RIGHT HEART FAILURE I50813 ACUTE ON CHRONIC RIGHT HEART FAILURE I50814 RIGHT HEART FAILURE DUE TO LEFT HEART FAILURE I5082 BIVENTRICULAR HEART FAILURE I5083 HIGH OUTPUT HEART FAILURE I5084 END STAGE HEART FAILURE I5089 OTHER HEART FAILURE I509 HEART FAILURE UNSPECIFIED I510 CARDIAC SEPTAL DEFECT, ACQURED I511 RUPTURE OF CHORDAE TENDINEAE, NOT ELSEWHERE CLASSIFIED I512 RUPTURE OF PAPILLARY MUSCLE, NOT ELSEWHERE CLASSIFIED
PG0478 – 12/07/2020 I513 INTRACARDIAC THROMBOSIS, NOT ELSEWHERE CLASSIFIED I514 MYOCARDITIS UNSPECIFIED I515 MYOCARDIAL DEGENERATION I517 CARDIOMEGALY I5181 TAKOTSUBO SYNDROME I5189 OTHER ILL-DEFINED HEART DISEASES I519 HEART DISEASE UNSPECIFIED Q200 COMMON ARTERIAL TRUNK Q201 DOUBLE OUTLET RIGHT VENTRICLE Q202 DOUBLE OUTLET LEFT VENTRICLE Q203 DISCORDANT VENTRICULOATRERIAL CONNECTION Q204 DOUBLE INLET VENTRICLE Q205 DISCORDANT ATRIOVENTRICULAR CONNECTION Q206 ISOMERISM OF ATRIAL APPENDAGES Q208 OTHER CONGENITAL MALFORMATIONS OF CARDIAC CHAMBERS AND CONNECTIONS Q209 CONGENITAL MALFORMATION OF CARDIAC CHAMBERS AND COMMECTIONS, UNSPECIFIED Q210 VENTRICULAR SEPTAL DEFECT Q211 ATRIAL SEPTAL DEFECT Q212 ARTIOVENTRICULAR SEPTAL DEFECT Q213 TETRALOGY OF FALLOT Q214 AORTOPULMONARY SEPTAL DEFECT Q218 OTHER CONGENITAL MALFORMATIONS OF CARDIAC SEPTA Q219 CONGENITAL MALFORMATION OF CARDIAC SEPTUM, UNSPECIFIED Q220 PULMONARY VALVE ATRESIA Q221 CONGENITAL PULMONARY VALVE STENOSIS Q222 CONGENITAL PULMONARY VALVE INSUFFICIENCY Q223 OTHER CONGENITAL MALFORMATIONS OF PULMONARY VALVE Q224 CONGENITAL TRICUSPID STENOSIS Q225 EBSTEIN’S ANOMALY Q226 HYPOPLASTIC RIGHT HEART SYNDROME Q228 OTHER CONGENITAL MALFORMATIONS OF TRICUSPID VALVE Q229 CONGENIAL MALFORMATION OF TRICUSPID VALVE, UNSPECIFIED Q230 CONGENITAL STENOSIS OF AORTIC VALVE Q231 CONGENITAL INSUFFICIENCY OF AORTIC VALVE Q232 CONGENITAL MITRAL STENOSIS Q233 CONGENITAL MITRAL INSUFFICIENCY Q234 HYPOPLASTIC LEFT HEART SYNDROM Q238 OTHER CONGENITAL MALFORMATIONS OF AORTIC AND MITRAL VALVES Q239 CONGENITAL MALFORMATION OF AOTRIC AND MITRAL VALVES, UNSPECIFIED Q240 DEXTROCARDIA Q241 LEVOCARDIA Q242 COR TRIATRIATUM Q243 PULMONARY INFUNDIBULAR STENOSIS Q244 CONGENITAL SUBAORTIC STENOSIS Q245 MALFORMATION OF CORONARY VESSELS Q246 CONGENITAL HEART BLOCK Q248 OTHER SPECIFIED CONGENITAL MALFORMATIONS OF HEART Q249 CONGENITAL MALFORMATION FO HEART, UNSPECIFIED Q250 PATENT DUCTUS ARTERIOSUS Q251 COARCTATION OF AORTA Q2521 INTERRUPTION OF AORTIC ARCH Q2529 OTHER ATRESIA OF AORTA
PG0478 – 12/07/2020 Q253 SUPRAVALVULAR AORTIC STENOSIS Q2540 CONGENITAL MALFORMATION OF AORTA UNSPECIFIED Q2541 ABSENCE AND APLASIA OF AORTA Q2542 HYPOPLASIA OF AORTA Q2543 CONGENITAL AUEURYSM OF AORTA Q2544 CONGENITAL DILATION OF AORTA Q2545 DOUBLE AORTIC ARCH Q2546 TORTUOUS AORTIC ARCH Q2547 RIGHT AORTIC ARCH Q2548 ANOMALOUS ORIGIN OF SUBCLAVIAN ARTERY Q2549 OTHER CONGENITAL MALFORMATIONS OF AORTA Q255 ATRESIA OF PULMONARY ARTERY Q256 STENOSIS OF PULMONARY ARTERY Q2571 COARCTATION OF PULMONARY ARTERY Q2572 CONGENITAL PULMONARY ARTERIOVENOUS MALFORMATION Q2579 OTHER CONGENITAL MALFORMATIONS OF PULMONARY ARTERY Q258 OTHER CONGENITAL MALFORMATIONS OF OTHER GREAT ARTERIES Q259 CONGENITAL MALFORMATIONS OF GREAT ARTERIES, UNSPECIFIED Q260 CONGENITAL STENOSIS OF VENA CAVA Q261 PERSISTENT LEFT SUPERIOR VENA CAVA Q262 TOTAL ANOMALOUS PULMMONARY VENOUS CONNECTION Q263 PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION Q264 ANOMALOUS PULMONARY VENOUS CONNECTIN, UNSPECIFIED Q265 ANOMALOUS PORTAL VENOUS CONNECTION Q266 PORTAL VEIN-HEPATIC ARTERY FISULA Q268 OTHER CONGENIAL MALFORMATIONS OF GREAT VEINS Q269 CONGENITAL MALFORMATION OF GREAT VEIN, UNSPECIFIED Q7960 EHLERS-DANLOS SYNDROME, UNSPECIFIED Q7961 CLAISSICAL EHLERS-DANLOS S YNDROME Q7962 HYPERMOBILE EHLERS-DANLOS SYNDROME Q7963 VASCULAR EHLERS-DANLOS SYNDROME Q7969 OTHER EHLERS-DANLOS SYNDROMES Q900 TRISOMY 21, NONMOSAICISM (MEIOTIC NONDISJUNCTION) Q901 TRISOMY 21, MOSAICISM (MITOTIC NONDISJUNCTION) Q902 TRISOMY 21, TRANSLOCATION Q909 DOWN SYNDROME UNSPECIFIED Q960 KARYOTHPE 45, X Q961 KARYOTYPE 46, X ISO (Xq) Q962 KARYOTHPE 46, X WITH ABNORMAL SEX CHROMOSOME, EXCEPT ISO (Xq) Q963 MOSAICISM, 45, X/46, XX OR XY Q964 MOSAICISM, 45, X/OTHER CELL LINE(S) WITH ABNORMAL SEX CHROMOSOME Q968 OTHER VARIANTS OF TURNER’S SYNDROME Q969 TURNERS SYNDROME UNSPECIFIED R000 TACHYCARDIA, UNSPECIFIED R001 BRADYCARDIA UNSPECIFIED R002 PALPITATIONS R008 OTHER ABNORMALITIES OF HEART BEAT R009 UNSPECIFIED ABNORMALITIES OF HEART BEAT R010 BENIGN AND INNOCENT CARDIAC MURMURS R011 CARDIAC MURMUR, UNSPECIFIED R012 OTHR CARDIAC SOUNDS R071 CHEST PAIN ON BREATHING
PG0478 – 12/07/2020 R072 PRECORDIAL PAIN R0781 PLEURODYNIA R0782 INTERCOSTAL PAIN R0789 OTHER CHEST PAIN R079 CHEST PAIN, UNSPECIFIED R94.31 ABNORMAL ELECTROCARDIOGRAM [ECG] [EKG] T8620 UNSPECIFIED COMPLICATION OF HEART TRANSPLANT T8621 HEART TRANSPLANT REJECTION T8622 HEART TRANSPLANT FAILURE T8623 HEART TRANSPLANT INFECTION T86290 CARDIAC ALLOGRAFT VASCULOPATHY T86298 OTHER COMPLICATIONS OF HEART TRANSPLANT T8630 UNSPECIFIED COMPLICATION OF HEART-LUNG TRANSPLANT T8631 HEART-LUNG TRANSPLANT REJECTION T8632 HEART-LUNT TRANSPLANT FAILURE T8633 HEART-LUNG TRANSPLANT INFECTION T8639 OTHER COMPLICATIONS OF HEART-LUNG TRANSPLANT Z01810 ENCOUNTER FOR PREPROCEDURAL CARDIOVASCULAR EXAMINATION Z01811 ENCOUNTER FOR PREPROCEDURAL RESPIRATORY EXAMINATION Z01818 ENCOUNTER FOR OTHER PREPROCEDURAL EXAMINATION Z8774 PERSONAL HX CONGEN MALFORM HEART & CIRC SYSTEM Z950 PRESENCE OF CARDIAC PACEMAKER Z951 PRESENCE OF AORTOCORONARY BYPASS GRAFT Z952 PRESENCE OF PROSTHETIC HEART VALVE Z953 PRESENCE OF XENOGENIC HEART VALVE Z954 PRESENCE OF OTHER HEART-VALVE REPLACEMENT Z955 PRESENCE OF CORONARY ANGIOPLASTY IMPLANT & GRAFT Z95810 PRESENCE AUTO IMPLANTABLE CARDIAC DEFIBRILLATOR Z95811 PRESENCE OF HEART ASSIST DEVICE Z95812 PRESENCE OF FULLY IMPLANTABLE ARTIFICIAL HEART Z95818 PRESENCE OF OTHER CARDIAC IMPLANTS AND GRAFTS Z95820 PERIPHERAL VASCULAR ANGIOPLASY STATUS WITH IMPLANTS AND GRAFTS Z95828 PRESENCE OF OTHER VASCULAR IMPLANTS AND GRAFTS Z959 PRESENT OF CARDIAC AND VASCULAR IMPLANT AND GRAFT, UNSPECIFIED MODIFIERS 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional
REVISION HISTORY EXPLANATION ORIGINAL EFFECTIVE DATE: 09/01/2020 08/01/2020: Policy created. 09/08/2020: Clarified EKG/ECG throughout the medical policy. Corrected a mistype in the diagnosis list, should be I310, I311, I312 not 1310, 1311, 1312. 12/07/2020: Placed medical policy on the new Paramount Medical Policy Format. Specified policy Scope.
REFERENCES/RESOURCES Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
PG0478 – 12/07/2020 American Academy of Family Physicians Industry Standard Review Hayes, Inc.
PG0478 – 12/07/2020