LCD for Transthoracic Echocardiography (TTE) (L1682)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1682 

 

LCD Title 

Transthoracic Echocardiography (TTE) 

 

Contractor's Determination Number 

1682 

 

AMA CPT / ADA CDT Copyright Statement 

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.  

 

CMS National Coverage Policy 

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section excludes coverage of items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 12/27/1996  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 03/10/2008  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Transthoracic echocardiography (TTE) affords unique insight into cardiac structure and function. Two dimensional imaging (2D) defines the configuration and changing dimensions of the chambers; dynamic cyclic variation in myocardial thickness; and the associated valvular motions throughout the cardiac cycle. Superimposition of Doppler velocity recordings (with volumetric flow calculations) provides an integrated picture of cardiac structure, function and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized.

The plethora of structural and functional information provided by TTE is unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has contributed to exponential application; and to potential over utilization. The National Claims History database attests to the growth of the application of TTE. In 1994 TTE (4 of 7333 CPT codes) accounted for 0.5% ($851 million) of the total Medicare expenditure of $162 billion. This policy addresses the medically necessary and appropriate application of TTE. Transesophageal echocardiography (TEE) is the subject of a separate policy statement.

Ventricular Function and Cardiomyopathies



Changes in myocardial thickness (hypertrophy and thinning), derived parameters of contractility, and in chamber volume and morphology can be quantified and charted over time by TTE. Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional perturbations to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types and absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration. It is not generally medically necessary to augment clinical assessments with TTE measurements at more frequent than annual examinations.

Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are to well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities. Because the TTE findings suggesting diastolic dysfunction are less well established, this application of TTE will be expected to be confined to examiners with published peer review recognition of expertise in ventricular diastolic functional assessment and treatment.

Hypertensive Cardiovascular Disease



Left ventricular hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of left ventricular hypertrophy. TTE may assist with the decision to treat and the analysis and formulation of a treatment program. Baseline follow-up or limited study TTE and periodic serial assessment (no more frequently than annually) would be medically appropriate. More frequent assessment should have explicit contemporaneous medical necessity documentation.

Acute Myocardial Infarction and Coronary Insufficiency



TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. Absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six (6) months and annually thereafter generally provides adequate supplemental data to a thoughtful clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment.

The role for TTE in the emergency room assessment of individuals presenting with chest pain is in evolution. Absent supporting clinical findings of myocardial dysfunction, this application is considered investigational and will be subjected to medical necessity review.

Exposure to Cardiotoxic Agents (chemotherapeutic and external)



Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six (6) months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered reasonable and medically necessary.

Cardiac Transplant and Rejection Monitoring



TTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluations focus on analysis of ventricular function and the integrity of valvular performance. TTE is also incorporated into the management of allograft recipients. Myocardial thickness, refractile properties, contractile patterns and indices, restrictive hemodynamics, and the late development of pericardial fluid may alert to a refection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight (4-8) weeks following transplant with decremental frequency subsequently. Absent acute refection episodes, approximately three (3) TTE examinations are typically performed yearly in chronic transplant recipients. TTE of cardiac allografts will most appropriately be performed at transplant centers by examiners with unique expertise in the management of cardiac allograft recipients. Other will be expected to provide appropriate medical necessity documentation.

Native Valvular Heart Disease


Detection of mitral stenosis was among the first practical clinical applications of TTE. TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multi valve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist; especially interventions for mitral stenosis. Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally it is not medically necessary to repeat these examinations more frequently than annually.

Prosthetic Heart Valves (Mechanical & Bio-prostheses)



TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile. Reassessment following convalescence (36 months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate.

Acute Endocarditis



TTE can provide diagnostic information; larger vegatations may be directly visualized, valvular anatomy, and ventricular function directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events; analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves. (vide supra).

Pericardial Disease



Detection, and quantitation of the amount, of pericardial effusion were among the first and remains an important application of TTE. Pericardial fluid accumulations of as little as twenty (20) milliliters have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. A collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually medically necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids.

Aortic Pathology



TTE can provide valuable information when acute or chronic aortic pathology is present. However, the posterior window of TEE, coupled with the more posterior position of the thoracic aorta has rendered TEE a more determinative study. Noninvasive TTE remains the study of choice for following chronic aortic pathology when images suitable for serial quantitation can be obtained. Repetition frequency should be guided by the pathophysiologic milieu.

Congenital Heart Disease



In children and small adults TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually providers accurate diagnosis and noninvasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation, if the frequency exceeds an annual evaluation.

Suspected Cardiac Thrombi and Embolic Sources



TTE is particularly sensitive in the detection of ventricular thrombi and potentially embolic material. Limited visualization of atrial interstices and the more peripheral and superior portions of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potentially embolic material. In individuals with cardiac pathology associated with a high incidence of thromboembolic (valvular heart disease, arrhythmias, -especially atrial fibrillation, cardiomyopathies and ventricular dysfunction). TTE usually provides adequate supplemental therapeutic decisional data. In those instances where the precise diagnosis and localization of potentially embolic material is of paramount therapeutic importance (e.g. younger stroke patients, generally #45 year old) and the information so obtained will potentially and substantively alter therapy, or the risk of anticoagulants is inordinately high, consideration should be given to TEE if TTE provides inadequate decisional information. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus and the findings of thrombus or vegetation does not establish a cardiac embolic source. Absent the definition of, and serial assessment for regression of, potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions.

Cardiac Tumors and Masses



Infiltrate and ventricular tumors and masses can be visualized, their extent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, etc.) extensions and attachments. These acute pathologies are not typically followed serially.

Critically Ill and Trauma Patients



There is a role for echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Perturbations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the exigencies of the clinical milieu.
 

 

Coverage Topic 

Diagnostic Tests and X-Rays
 

 

Coding Information

Bill Type Codes: 

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.

12x

Hospital-inpatient or home health visits (Part B only)

13x

Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)

15x

Hospital-intermediate care - level I

16x

Hospital-intermediate care - level II

17x

Hospital-intermediate care - level III

18x

Hospital-swing beds

19x

Hospital-reserved for national assignment

21x

SNF-inpatient, Part A

22x

SNF-inpatient or home health visits (Part B only)

23x

SNF-outpatient (HHA-A also)

24x

SNF-other (Part B)

25x

SNF-intermediate care - level I

26x

SNF-intermediate care - level II

27x

SNF-intermediate care - level III

28x

SNF-swing beds

29x

SNF-reserved for national assignment

31x

HHA-inpatient (including Part A)

32x

HHA-inpatient or home health visits (Part B only)

33x

HHA-outpatient (HHA-A also)

34x

HHA-other (Part B)

35x

HHA-intermediate care - level I

36x

HHA-intermediate care - level II

37x

HHA-intermediate care - level III

38x

HHA-swing beds

39x

HHA-reserved for national assignment

41x

Religious Nonmedical Health Care Institution (RNHCI) hospital-inpatient (including Part A) (all references to Christian Science (CS) is obsolete eff. 8/00 and replaced with RNHCI)

42x

RNHCI hospital-inpatient or home health visits (Part B only)

43x

RNHCI hospital-outpatient (HHA-A also)

44x

RNHCI hospital-other (Part B)

45x

RNHCI hospital-intermediate care - level I

46x

RNHCI hospital-intermediate care - level II

47x

RNHCI hospital-intermediate care - level III

48x

RNHCI hospital-swing beds

49x

RNHCI hospital-reserved for national assignment

51x

CS extended care-inpatient (including Part A) OBSOLETE eff. 7/00 - implementation of Religious Nonmedical Health Care Institutions (RNHCI)

52x

RNHCI extended care-inpatient or home health visits (Part B only) (eff. 7/00); prior to 7/00 Christian Science (CS)

53x

RNHCI extended care-outpatient (HHA-A also) (eff. 7/00); prior to 7/00 referenced CS

54x

RNHCI extended care-other (Part B)(eff. 7/00); prior to 7/00 referenced CS

55x

RNHCI extended care-intermediate care - level I (eff. 7/00) prior to 7/00 referenced CS

56x

RNHCI extended care-intermediate care - level II (eff. 7/00) prior to 7/00 referenced CS

57x

RNHCI extended care-intermediate care - level III (eff. 7/00) prior to 7/00 referenced CS

58x

RNHCI extended care-swing beds (eff. 7/00) prior to 7/00 referenced CS

59x

RNHCI extended care-reserved for national assignment (eff. 7/00); prior to 7/00 referenced CS

61x

Intermediate care-inpatient (including Part A)

62x

Intermediate care-inpatient or home health visits (Part B only)

63x

Intermediate care-outpatient (HHA-A also)

64x

Intermediate care-other (Part B)

65x

Intermediate care-intermediate care - level I

66x

Intermediate care-intermediate care - level II

67x

Intermediate care-intermediate care - level III

68x

Intermediate care-swing beds

69x

Intermediate care-reserved for national assignment

71x

Clinic-rural health

72x

Clinic-hospital based or independent renal dialysis facility

 

 

Revenue Codes: 

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.

 

0480

Cardiology-general classification

 

 

CPT/HCPCS Codes 

Effective January 1, 2008, CPT/HCPCS codes 93320, 93321 and 93325 will be packaged into other payable services on the same date of service.

93307

ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE

93308

ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; 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)

C8923

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE

C8924

TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY

 

 

ICD-9 Codes that Support Medical Necessity 

 

017.90 - 017.96

TUBERCULOSIS OF OTHER SPECIFIED ORGANS UNSPECIFIED EXAMINATION - TUBERCULOSIS OF OTHER SPECIFIED ORGANS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

032.82

DIPHTHERITIC MYOCARDITIS

074.21

COXSACKIE PERICARDITIS

074.22

COXSACKIE ENDOCARDITIS

074.23

COXSACKIE MYOCARDITIS

086.0

CHAGAS' DISEASE WITH HEART INVOLVEMENT

088.81

LYME DISEASE

093.0

ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC

093.1

SYPHILITIC AORTITIS

093.20

SYPHILITIC ENDOCARDITIS OF VALVE UNSPECIFIED

093.21

SYPHILITIC ENDOCARDITIS OF MITRAL VALVE

093.22

SYPHILITIC ENDOCARDITIS OF AORTIC VALVE

093.23

SYPHILITIC ENDOCARDITIS OF TRICUSPID VALVE

093.24

SYPHILITIC ENDOCARDITIS OF PULMONARY VALVE

093.81

SYPHILITIC PERICARDITIS

093.82

SYPHILITIC MYOCARDITIS

098.83

GONOCOCCAL PERICARDITIS

098.84

GONOCOCCAL ENDOCARDITIS

098.85

OTHER GONOCOCCAL HEART DISEASE

112.81

CANDIDAL ENDOCARDITIS

115.03

HISTOPLASMA CAPSULATUM PERICARDITIS

115.04

HISTOPLASMA CAPSULATUM ENDOCARDITIS

115.13

HISTOPLASMA DUBOISII PERICARDITIS

115.14

HISTOPLASMA DUBOISII ENDOCARDITIS

130.3

MYOCARDITIS DUE TO TOXOPLASMOSIS

135

SARCOIDOSIS

164.1

MALIGNANT NEOPLASM OF HEART

198.89

SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

212.7

BENIGN NEOPLASM OF HEART

238.8

NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES

239.8

NEOPLASM OF UNSPECIFIED NATURE OF OTHER SPECIFIED SITES

275.0

DISORDERS OF IRON METABOLISM

276.50

VOLUME DEPLETION, UNSPECIFIED

276.51

DEHYDRATION

276.52

HYPOVOLEMIA

277.30

AMYLOIDOSIS, UNSPECIFIED

277.39

OTHER AMYLOIDOSIS

391.0

ACUTE RHEUMATIC PERICARDITIS

391.1

ACUTE RHEUMATIC ENDOCARDITIS

391.2

ACUTE RHEUMATIC MYOCARDITIS

391.8

OTHER ACUTE RHEUMATIC HEART DISEASE

391.9

ACUTE RHEUMATIC HEART DISEASE UNSPECIFIED

392.0

RHEUMATIC CHOREA WITH HEART INVOLVEMENT

393

CHRONIC RHEUMATIC PERICARDITIS

394.0

MITRAL STENOSIS

394.1

RHEUMATIC MITRAL INSUFFICIENCY

394.2

MITRAL STENOSIS WITH INSUFFICIENCY

394.9

OTHER AND UNSPECIFIED MITRAL VALVE DISEASES

395.0

RHEUMATIC AORTIC STENOSIS

395.1

RHEUMATIC AORTIC INSUFFICIENCY

395.2

RHEUMATIC AORTIC STENOSIS WITH INSUFFICIENCY

395.9

OTHER AND UNSPECIFIED RHEUMATIC AORTIC DISEASES

396.0

MITRAL VALVE STENOSIS AND AORTIC VALVE STENOSIS

396.1

MITRAL VALVE STENOSIS AND AORTIC VALVE INSUFFICIENCY

396.2

MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE STENOSIS

396.3

MITRAL VALVE INSUFFICIENCY AND AORTIC VALVE INSUFFICIENCY

396.8

MULTIPLE INVOLVEMENT OF MITRAL AND AORTIC VALVES

396.9

MITRAL AND AORTIC VALVE DISEASES UNSPECIFIED

397.0

DISEASES OF TRICUSPID VALVE

397.1

RHEUMATIC DISEASES OF PULMONARY VALVE

397.9

RHEUMATIC DISEASES OF ENDOCARDIUM VALVE UNSPECIFIED

398.0

RHEUMATIC MYOCARDITIS

398.90

RHEUMATIC HEART DISEASE UNSPECIFIED

398.91

RHEUMATIC HEART FAILURE (CONGESTIVE)

398.99

OTHER RHEUMATIC HEART DISEASES

402.91

UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE

410.00

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED

410.01

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL INITIAL EPISODE OF CARE