Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27478

Cardiovascular Stress Testing

L27478

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.

A stress test evaluates heart action during physical or pharmacological stress to test cardiac reaction to increased demand for oxygen. It provides important diagnostic information that cannot be obtained from a resting electrocardiogram or echocardiogram alone. The preferred method of stress involves either bicycle or treadmill, symptom-limited, exercise testing. If the patient is unable to perform adequate exercise, pharmacological stress becomes the preferred method. Unless complications that are not perceived by the patient develop, the test continues until the patient reaches his/her target heart rate or experiences chest pain or fatigue.

Cardiac stress tests are performed to guide the management of individuals with known or suspected coronary artery disease.

Indications for CPT codes 93015-93018

Most Cardiovascular Stress or Exercise Testing is done for patients with symptoms of known or suspected ischemic heart disease. It is also useful for patients who have had a myocardial infarction and/or revascularization procedure. Specific indications and contraindications have been addressed by the American College of Cardiology (ACC) and the American Heart Association (AHA) in their Exercise Testing Guidelines (Gibbons, 1997). Class I indications are those "conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective". Class II indications are those "conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment"; Class IIa are those indications for which the "weight of evidence/opinion is in favor of usefulness/efficacy".

Cardiovascular Stress Testing may be indicated for patients with ACC/AHA Class I and IIa indications for Exercise Testing; and for patients who have additional indications for pharmacologic stress testing and/or the use of other imaging modalities. Indications may include:

• "Adult patients (including those with complete right bundle branch block or less than 1 mm of resting ST depression) with an intermediate pretest probability of CAD (Coronary Artery Disease), based on gender, age, and symptoms."
• "Patients with vasospastic angina."
• "Patients undergoing initial evaluation with suspected or known CAD."
• "Patients with suspected or known CAD previously evaluated with significant change in clinical status."
• Patients with myocardial infarction "before discharge for prognostic assessment, activity prescription, or evaluation of medical therapy (submaximal at about 4 to 7 days)."
• Patients with myocardial infarction "early after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the predischarge exercise test was not done (symptom-limited/about 14 to 21 days)."
• Patients with myocardial infarction "late after discharge for prognostic assessment, activity prescription, evaluation of medical therapy, and cardiac rehabilitation if the early exercise test was submaximal (symptom-limited/about 3 to 6 weeks)."
• Patients with myocardial infarction "after discharge for activity counseling and/or exercise training as part of cardiac rehabilitation in patients who have undergone coronary revascularization".
• "Evaluation of exercise capacity and response to therapy in patients with heart failure who are being considered for heart transplantation."
• Patients for whom "assistance in differentiating cardiac versus pulmonary limitations as a cause of exercise-induced dyspnea or impaired exercise capacity when the cause is uncertain" is needed.
• "Evaluation of exercise capacity when indicated for medical reasons in patients in whom subjective assessment of maximal exercise is unreliable."
• Patients who require "demonstration of proof of ischemia before revascularization".
• "Evaluation of patients with recurrent symptoms suggesting ischemia after revascularization."
• "After discharge for activity counseling and/or exercise training as part of cardiac rehabilitation in patients who have undergone coronary revascularization".
• "Identification of appropriate settings in patients with rate-adaptive pacemakers."
• "Evaluation of patients with known or suspected exercise-induced arrhythmias."
• "Evaluation of medical, surgical, or ablative therapy in patients with exercise-induced arrhythmias (including atrial fibrillation)."
• Evaluation of exercise capacity of selected patients with valvular heart disease with related symptomatology.

General contraindications to Cardiovascular Stress Testing include but are not limited to:

Absolute Contraindications:

• Very recent acute myocardial infarction (generally < 2 days)
• Unstable angina not previously stabilized by medical therapy
• Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic congestive heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute aortic dissection
• Hypotension (generally < 90mmHg systolic)
• Severe ST segment depression at rest
• Acute thrombophlebitis or deep vein thrombosis
• Acute pericarditis, myocarditis or endocarditis
• Severe symptomatic left ventricular dysfunction

Relative Contraindications:

• Uncontrolled metabolic disease, such as diabetes, thyrotoxicosis or myxedema
• Suspected left main coronary artery (or equivalent) stenosis
• Second or third degree heart block
• Severe aortic valvular heart disease
• Severe arterial hypertension (generally > 180 mmHg systolic or > 110mmHg diastolic)
• Acute or serious noncardiac disorder
• Significant and / or acute anemia
• Moderate stenotic valvular disease
• Tachyarrhythmias or bradyarrhythmias
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Mental and physical impairment leading to inability to exercise adequately
• High degree atrioventricular block

Stress testing is not covered for screening of asymptomatic patients regardless of the number of risk factors that may be present.

Pharmacologic cardiovascular stress testing (with persantine, adenosine, or dobutamine) is indicated when the patient is unable to exercise adequately because of physical limitations (eg, arthritis, amputations, severe peripheral vascular disease, severe chronic obstructive pulmonary disease, general debility) and for those individuals with a baseline left bundle branch block. Documentation in the patient's record must clearly indicate why the patient cannot undergo exercise stress testing.

A stress test must be ordered by a physician or qualified non-physician provider.

The resting 12 lead EKG and rhythm strip are considered to be part of the stress test. These services are not separately reimbursable.

The initiation of an intravenous line and infusion of a pharmacological agent are considered to be a part of the test, and are not separately reimbursable.

Indications for CPT code 93350 and C8928

To enhance the diagnostic specificity, the stress test may be combined with echocardiographic imaging. A contrast agent is frequently used with echographic imaging to enhance diagnostic accuracy. Stress echocardiography may be indicated in the care of patients with real or suspected ischemic heart disease in the following clinical settings:

• To detect coronary artery disease in patients presenting with chest pains, including atypical chest pains and exertional dyspnea, when the suspicion of CAD is high.
• To assess prognosis and functional capacity in patients following an acute myocardial infarction.
• To evaluate the extent of exercise induced ischemia in patients who have had a revascularization procedure (PCTA, stent or coronary bypass) or patients who have known CAD disease.
• To evaluate a prior nondiagnostic or abnormal ECG exercise test as a substitute for a nuclear perfusion study.
• To evaluate patients who are at high risk for myocardial infarction prior to a scheduled major vascular surgical procedure or transplant procedure.
• To evaluate patients presenting with various arrhythmias (atrial and/or ventricular) or syncope (near or pre), when the suspicion of occult coronary artery disease is high.
• To evaluate patients when an indicated standard exercise ECG is likely to be non-diagnostic, including patients with an abnormal resting ECG; orthostatic or hyperventilation induced ECG changes; non specific ST-T abnormalities due to ventricular hypertrophy, drugs, or associated intraventricular conduction defect.

Additionally the test may be combined with doppler intervention to evaluate exercise hemodynamics in patients with mitral stenosis, mitral regurgitation, pulmonary hypertension, aortic stenosis/regurgitation, prosthetic valves and other conditions where symptoms suggest a more severe impairment than the assessment done at rest.

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. Contrast echocardiography is not covered when used to evaluate perfusion.

Limitations

In addition to the general contraindications to cardiovascular stress testing listed above, there are additional contraindications for the use of pharmacologic stress agents such as dipyridamole, adenosine, and dobutamine. These include but are not limited to:

• History of reactive airway disease (asthma)
• Active bronchospastic disease
• History of tachyarrhythmias
• Second-degree AV block
• Oral dipyridamole
• Xanthine derivatives (theophylline; caffeine)
• Atrial fibrillation with rapid ventricular response
• Severe prostatic hypertrophy

Stress echocardiography used as a screening test for ischemic heart disease in a patient without signs or symptoms is not covered.

Studies with or without contrast will be considered a single study, whether performed on the same or subsequent days.

Contrast echocardiography is not covered when used to evaluate perfusion.

In order to provide economic quality healthcare and avoid the need for multiple tests, physicians should initially use the testing modality most specific to the needs of the individual patient. Stress tests by multiple modalities (e.g., echocardiography, SPECT) for the same clinical event are covered only if the first stress testing modality was inconclusive or uninterpretable.

Credentialing

Stress Testing

Stress testing should be conducted by well trained personnel. Only technicians and physicians familiar with normal and abnormal responses during exercise are trained to recognize or prevent untoward events. Equipment, medications and personnel trained to provide cardiopulmonary resuscitation (CPR) must be readily available.

Stress Echocardiography

For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions:

• The service is performed by a physician; or
• The service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or
• The service is performed at a laboratory (e.g. office, IDTF), credentialed by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL).

For the professional portion, an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements:

• The physician is board certified in Cardiovascular Diseases; or
• The physician has Level II training in transthoracic echocardiography, as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document; or
• The physician provides the interpretation in conjunction with a study that is performed at a laboratory that is accredited by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories and that is subject to such laboratory's quality assurance policies and procedures; or
• The physician has staff privileges to interpret echocardiograms at a hospital that participates in the Medicare program.

The submission of claims for stress echocardiography will be considered an attestation that both the technical and professional components of the service were provided within the context of the above stated credentials.

Diagnostic Tests and X-Rays

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.
     
4. Each test must have a written report which must include the following:
   • Name of beneficiary
   • Date of study
   • Ordering physician
   • Underlying diagnosis/symptoms
   • Reason for the stress test
   • Protocol used
   • Exercise performed with symptoms or response to pharmacological provocation
   • Heart rate, blood pressure, and ECG responses
   • Echocardiographic report with specific description of wall motion abnormalities (if applicable)
   • Copies of all tracings and echocardiographic recordings
   • Overall impression or interpretation
   • Signature of performing provider.
     
     
5. The specific reasons to perform the stress echo in instances where another imaging test has been performed need to be documented in the patient's medical record. The provider of the stress echo will be responsible for submitting such documentation to the contractor when requested.
   
   
6. When repeating stress tests, the medical record documentation must identify separate clinical indications, regardless of the ICD-9 code submitted for the test.

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

Barring a new episode of illness, services at a frequency of greater than two (2) per year will be denied as not reasonable and necessary.

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, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27478

05/22/2008

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