CMS Limitations Guide - Cardiovascular Services Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: https://www.cms.gov/medicare-coverage- database/overview-and-quick- search.aspx?clickon=search. CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient’s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: www.munsonhealthcare.org/medicalnecessity. If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 935- 7493.
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CMS Limitations Guide - Cardiovascular Services
Starting October 1, 2015, CMS will update their
existing medical necessity limitations on tests and
procedures to correspond to ICD-10 codes. This
limitations guide provides you with the latest
changes.
This guide is not an all-inclusive list of National
Coverage Documents (NCD) and Local Coverage
Documents (LCD). You can search by LCD or NCD or
keyword and region on the CMS website at:
https://www.cms.gov/medicare-coverage-
database/overview-and-quick-
search.aspx?clickon=search.
CMS will deny payment if the correct diagnosis
codes are not entered on the order form, and your
patient’s test or procedure will not be covered. We
compiled this information in one location to make it
easier for you to find the proper codes for medically
necessary diagnoses.
It is the responsibility of the provider to code to the
highest level specified in the ICD-10-CM. The correct
use of an ICD-10-CM code listed below does not
assure coverage of a service. The service must be
reasonable and necessary in the specific case and
must meet the criteria specified in this
determination.
We will continue to update this list as new CMS
limitations are announced. You can always find the
most current list at:
www.munsonhealthcare.org/medicalnecessity.
If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Popa, Director, Patient Access Services, at (231) 935-7493.
93303 Transthoracic echocardiography for congenital cardiac anomalies; complete
93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study
93306 Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography (2D Echo Doppler) (3D Echo) (Echo)
93307 Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography
93308 Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, follow-up or limited study
93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); complete
93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (list separately in addition to codes for echocardiographic imaging); follow-up or limited study (list separately in addition to codes for echocardiographic imaging)
93325 Doppler echocardiography color flow velocity mapping (list separately in addition to codes for echocardiography)
93350 Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report;
93351 Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional (Echo Dobutamine) (Stress Echo)
93352 Use of echocardiographic contrast agent during stress echocardiography (list separately in addition to code for primary procedure)
C8921 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; complete
C8922 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, for congenital cardiac anomalies; follow-up or limited study
C8923 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, without spectral or color doppler echocardiography
C8924 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, follow-up or limited study
C8928 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report
C8929 Transthoracic echocardiography with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography
C8930 Transthoracic echocardiography, with contrast, or without contrast followed by with contrast, real-time with image documentation (2d), includes m-mode recording, when performed, during
CMS Limitations Guide – Cardiovascular Services
rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision
Group 2 Paragraph: HCPCS Contrast Agent Codes Group 2 Codes:
Code Description
A9700 Supply of injectable contrast material for use in echocardiography, per study
Q9955 Injection, perflexane lipid microspheres, per ml
Q9956 Injection, octafluoropropane microspheres, per ml
Q9957 Injection, perflutren lipid microspheres, per ml
ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program: Group 1 Paragraph: Note: ICD-10 codes must be coded to the highest level of specificity. For use with CPT codes 93303, 93304, 93306, 93307, 93308, 93320, 93321, 93325, 93350, 93351 Group 1 Codes:
Code Description
A02.1 Salmonella sepsis
A18.84 Tuberculosis of heart
A22.7 Anthrax sepsis
A26.7 Erysipelothrix sepsis
A32.7 Listerial sepsis
A40.0 Sepsis due to streptococcus, group A
A40.1 Sepsis due to streptococcus, group B
A40.3 Sepsis due to Streptococcus pneumoniae
A40.8 Other streptococcal sepsis
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1 Sepsis due to other specified staphylococcus
A41.3 Sepsis due to Hemophilus influenzae
A41.4 Sepsis due to anaerobes
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.59 Other Gram-negative sepsis
CMS Limitations Guide – Cardiovascular Services
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
A42.7 Actinomycotic sepsis
A52.01 Syphilitic aneurysm of aorta
A52.02 Syphilitic aortitis
A52.03 Syphilitic endocarditis
A52.04 Syphilitic cerebral arteritis
A52.05 Other cerebrovascular syphilis
A52.06 Other syphilitic heart involvement
A52.09 Other cardiovascular syphilis
A54.83 Gonococcal heart infection
A54.86 Gonococcal sepsis
A69.21 Meningitis due to Lyme disease
A69.22 Other neurologic disorders in Lyme disease
A69.23 Arthritis due to Lyme disease
A69.29 Other conditions associated with Lyme disease
B20 Human immunodeficiency virus [HIV] disease
B33.21 Viral endocarditis
B33.22 Viral myocarditis
B33.23 Viral pericarditis
B37.6 Candidal endocarditis
B37.7 Candidal sepsis
B44.81 Allergic bronchopulmonary aspergillosis
B57.0 Acute Chagas' disease with heart involvement
B57.2 Chagas' disease (chronic) with heart involvement
B58.81 Toxoplasma myocarditis
C38.0 Malignant neoplasm of heart
C45.2 Mesothelioma of pericardium
C79.89 Secondary malignant neoplasm of other specified sites
C96.5 Multifocal and unisystemic Langerhans-cell histiocytosis
C96.6 Unifocal Langerhans-cell histiocytosis
D15.1 Benign neoplasm of heart
D48.7 Neoplasm of uncertain behavior of other specified sites
Q98.1 Klinefelter syndrome, male with more than two X chromosomes
Q98.3 Other male with 46, XX karyotype
R00.0 Tachycardia, unspecified
R00.1 Bradycardia, unspecified
R00.2 Palpitations
R00.8 Other abnormalities of heart beat
R01.0 Benign and innocent cardiac murmurs
R01.2 Other cardiac sounds
R04.2 Hemoptysis
R04.81 Acute idiopathic pulmonary hemorrhage in infants
R04.89 Hemorrhage from other sites in respiratory passages
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.2 Wheezing
R06.3 Periodic breathing
R06.4 Hyperventilation
R06.81 Apnea, not elsewhere classified
R06.82 Tachypnea, not elsewhere classified
R06.83 Snoring
R06.89 Other abnormalities of breathing
R07.1 Chest pain on breathing
CMS Limitations Guide – Cardiovascular Services
R07.2 Precordial pain
R07.81 Pleurodynia
R07.82 Intercostal pain
R07.89 Other chest pain
R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems
R22.2 Localized swelling, mass and lump, trunk
R23.0 Cyanosis
R42 Dizziness and giddiness
R47.01 Aphasia
R50.2 Drug induced fever
R50.81 Fever presenting with conditions classified elsewhere
R50.82 Postprocedural fever
R50.83 Postvaccination fever
R50.84 Febrile nonhemolytic transfusion reaction
R55 Syncope and collapse
R57.0 Cardiogenic shock
R57.1 Hypovolemic shock
R60.0 Localized edema
R60.1 Generalized edema
R65.10 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ
dysfunction
R65.11 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ
dysfunction
R65.20 Severe sepsis without septic shock
R65.21 Severe sepsis with septic shock
R68.0 Hypothermia, not associated with low environmental temperature
R68.83 Chills (without fever)
R68.89 Other general symptoms and signs
R78.81 Bacteremia
R94.31 Abnormal electrocardiogram [ECG] [EKG]
R94.39 Abnormal result of other cardiovascular function study
T86.21 Heart transplant rejection
T86.22 Heart transplant failure
T86.23 Heart transplant infection
T86.290 Cardiac allograft vasculopathy
CMS Limitations Guide – Cardiovascular Services
T86.298 Other complications of heart transplant
T86.31 Heart-lung transplant rejection
T86.32 Heart-lung transplant failure
T86.33 Heart-lung transplant infection
T86.39 Other complications of heart-lung transplant
T86.810 Lung transplant rejection
T86.811 Lung transplant failure
T86.812 Lung transplant infection
T86.818 Other complications of lung transplant
Z01.810 Encounter for preprocedural cardiovascular examination
Z03.89 Encounter for observation for other suspected diseases and conditions ruled out
Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm
Z09 Encounter for follow-up examination after completed treatment for conditions other than
malignant neoplasm
Z21 Asymptomatic human immunodeficiency virus [HIV] infection status
Z48.21 Encounter for aftercare following heart transplant
Z48.24 Encounter for aftercare following lung transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy
Z51.81 Encounter for therapeutic drug level monitoring
Z52.89 Donor of other specified organs or tissues
Z79.3 Long term (current) use of hormonal contraceptives
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z94.1 Heart transplant status
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
Z94.5 Skin transplant status
Z95.0 Presence of cardiac pacemaker
Z95.2 Presence of prosthetic heart valve
Z95.3 Presence of xenogenic heart valve
Z95.4 Presence of other heart-valve replacement
Z95.810 Presence of automatic (implantable) cardiac defibrillator
Z95.811 Presence of heart assist device
CMS Limitations Guide – Cardiovascular Services
Z95.818 Presence of other cardiac implants and grafts
Z98.89 Other specified postprocedural states
Group 2 Paragraph: The following codes should be billed with the appropriate 7th digit: A (Initial encounter), D (Subsequent Encounter) or S (Sequela). Group 2 Codes:
Code Description
S22.5XXA Flail chest, initial encounter for closed fracture
S22.5XXB Flail chest, initial encounter for open fracture
S25.01XA Minor laceration of thoracic aorta, initial encounter
S25.02XA Major laceration of thoracic aorta, initial encounter
S25.09XA Other specified injury of thoracic aorta, initial encounter
S25.21XA Minor laceration of superior vena cava, initial encounter
S25.22XA Major laceration of superior vena cava, initial encounter
S25.401A Unspecified injury of right pulmonary blood vessels, initial encounter
S25.402A Unspecified injury of left pulmonary blood vessels, initial encounter
S25.411A Minor laceration of right pulmonary blood vessels, initial encounter
S25.412A Minor laceration of left pulmonary blood vessels, initial encounter
S25.421A Major laceration of right pulmonary blood vessels, initial encounter
S25.422A Major laceration of left pulmonary blood vessels, initial encounter
S25.491A Other specified injury of right pulmonary blood vessels, initial encounter
S25.492A Other specified injury of left pulmonary blood vessels, initial encounter
S26.01XA Contusion of heart with hemopericardium, initial encounter
S26.020A Mild laceration of heart with hemopericardium, initial encounter
S26.021A Moderate laceration of heart with hemopericardium, initial encounter
S26.022A Major laceration of heart with hemopericardium, initial encounter
S26.09XA Other injury of heart with hemopericardium, initial encounter
S26.11XA Contusion of heart without hemopericardium, initial encounter
S26.12XA Laceration of heart without hemopericardium, initial encounter
S26.19XA Other injury of heart without hemopericardium, initial encounter
S26.91XA Contusion of heart, unspecified with or without hemopericardium, initial encounter
S26.92XA Laceration of heart, unspecified with or without hemopericardium, initial encounter
S26.99XA Other injury of heart, unspecified with or without hemopericardium, initial encounter
T38.0X1A Poisoning by glucocorticoids and synthetic analogues, accidental (unintentional), initial
encounter
CMS Limitations Guide – Cardiovascular Services
T38.0X2A Poisoning by glucocorticoids and synthetic analogues, intentional self-harm, initial encounter
T38.0X3A Poisoning by glucocorticoids and synthetic analogues, assault, initial encounter
T38.0X4A Poisoning by glucocorticoids and synthetic analogues, undetermined, initial encounter
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.0X3A Poisoning by opium, assault, initial encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.4X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter
T40.4X2A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter
T40.4X3A Poisoning by other synthetic narcotics, assault, initial encounter
T40.4X4A Poisoning by other synthetic narcotics, undetermined, initial encounter
T40.601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter
T40.602A Poisoning by unspecified narcotics, intentional self-harm, initial encounter
T40.603A Poisoning by unspecified narcotics, assault, initial encounter
T40.604A Poisoning by unspecified narcotics, undetermined, initial encounter
T45.1X1A Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional), initial
encounter
T45.1X2A Poisoning by antineoplastic and immunosuppressive drugs, intentional self-harm, initial
encounter
T45.1X3A Poisoning by antineoplastic and immunosuppressive drugs, assault, initial encounter
T45.1X4A Poisoning by antineoplastic and immunosuppressive drugs, undetermined, initial encounter
T46.2X1A Poisoning by other antidysrhythmic drugs, accidental (unintentional), initial encounter
T46.2X2A Poisoning by other antidysrhythmic drugs, intentional self-harm, initial encounter
CMS Limitations Guide – Cardiovascular Services
T46.2X3A Poisoning by other antidysrhythmic drugs, assault, initial encounter
T46.2X4A Poisoning by other antidysrhythmic drugs, undetermined, initial encounter
T50.0X1A Poisoning by mineralocorticoids and their antagonists, accidental (unintentional), initial
encounter
T50.0X2A Poisoning by mineralocorticoids and their antagonists, intentional self-harm, initial encounter
T50.0X3A Poisoning by mineralocorticoids and their antagonists, assault, initial encounter
T50.0X4A Poisoning by mineralocorticoids and their antagonists, undetermined, initial encounter
T50.905A Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter
T51.3X1A Toxic effect of fusel oil, accidental (unintentional), initial encounter
T51.3X2A Toxic effect of fusel oil, intentional self-harm, initial encounter
T51.3X3A Toxic effect of fusel oil, assault, initial encounter
T51.3X4A Toxic effect of fusel oil, undetermined, initial encounter
T52.3X1A Toxic effect of glycols, accidental (unintentional), initial encounter
T52.3X2A Toxic effect of glycols, intentional self-harm, initial encounter
T52.3X3A Toxic effect of glycols, assault, initial encounter
T52.3X4A Toxic effect of glycols, undetermined, initial encounter
T58.01XA Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional), initial
encounter
T58.02XA Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm, initial
encounter
T58.03XA Toxic effect of carbon monoxide from motor vehicle exhaust, assault, initial encounter
T58.04XA Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined, initial encounter
T58.11XA Toxic effect of carbon monoxide from utility gas, accidental (unintentional), initial encounter
T58.12XA Toxic effect of carbon monoxide from utility gas, intentional self-harm, initial encounter
T58.13XA Toxic effect of carbon monoxide from utility gas, assault, initial encounter
T58.14XA Toxic effect of carbon monoxide from utility gas, undetermined, initial encounter
T58.2X1A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels,
accidental (unintentional), initial encounter
T58.2X2A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels,
intentional self-harm, initial encounter
T58.2X3A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault,
initial encounter
T58.2X4A Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels,
undetermined, initial encounter
T58.8X1A Toxic effect of carbon monoxide from other source, accidental (unintentional), initial encounter
T58.8X2A Toxic effect of carbon monoxide from other source, intentional self-harm, initial encounter
T58.8X3A Toxic effect of carbon monoxide from other source, assault, initial encounter
T58.8X4A Toxic effect of carbon monoxide from other source, undetermined, initial encounter