Post on 03-Aug-2020
POLICY: PG0478
ORIGINAL EFFECTIVE: 09/08/20
LAST REVIEW:
MEDICAL POLICY Electrocardiograms
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.
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.
HMO, PPO, Individual Marketplace, Elite, 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,
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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.
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
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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)
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
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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
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
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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
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
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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
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
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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
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
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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
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
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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
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
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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
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
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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
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
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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
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
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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:
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.
REFERENCES/RESOURCES:
Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Ohio Department of Medicaid http://jfs.ohio.gov/ 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 American Academy of Family Physicians Industry Standard Review Hayes, Inc.