LCD for Troponin (L1686)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1686 

 

LCD Title 

Troponin 

 

Contractor's Determination Number 

L1686 

 

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
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Tennessee
Texas
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West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 09/28/2000  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 12/09/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Troponin is a muscle protein that attaches to both actin and tropomyosin, It is concerned with calcium binding and inhibiting cross-bridge formation. Troponin is a complex of three proteins: troponin C, troponin, I and troponin T. The distribution of these isoforms varies between cardiac muscle and slow and fast-twitch skeletal muscle. Their importance lies in the fact that the isoforms troponin I and troponin T show a high degree of cardiac specificity, and therefore, have an important role in the diagnostic evaluation of a patient presenting with symptoms suggestive of a cardiac origin.

Cardiac Troponin I (cTnI) is highly specific for myocardial tissue, is thirteen times more abundant in the myocardium than CK-MB on a weight basis, is not detectable in the blood of healthy persons, shows a greater proportional increase above the upper limit of the reference interval in patients with myocardial infarction and remains elevated for seven to ten days after an episode of myocardial necrosis. In addition, measurements of cTnl is useful to clarify which increases in CK-MB are due to myocardial injury and which reflect acute or chronic skeletal muscle abnormalities.

Troponin T, the tropomyosin-binding protein of the regulatory complex located on the contractile apparatus of cardiac myocytes, is also a sensitive and specific maker for myocardial necrosis. Damaged heart muscle releases the protein, troponin T, which increases in the bloodstream as early as 3 hours after the onset of chest pain and remains at an elevated level for 2 to 7 days.

Troponin levels are considered medically reasonable and necessary to rule out myocardial injury only under the following conditions:

Patient presents with signs and symptoms of an acute myocardial infarction (prolonged chest pain often described as squeezing, choking, stabbing, etc., usually spreading across chest to the left arm; dyspnea, diaphoresis) which is confirmed by an electrocardiogram (EKG, ECG);

Patient presents with vague or atypical symptoms suggestive of a cardiac origin, which is not confirmed by an electrocardiogram; or

Patient with acute EKG changes suggestive of an acute myocardial infarction, with atypical signs and symptoms.

Patient presents with the diagnosis of unstable angina and a non Q-wave myocardial infarction with no ST elevation on the EKG.

Initially, it is expected that a qualitative Troponin level (procedure code 84512) is performed on a patient with suspected myocardial injury. If the results of the qualitative Troponin level is positive, then the quantitative level of Troponin I or Troponin T (procedure code 84484) is performed, usually with the same blood specimen, to determine if the symptoms are cardiac in nature. The Troponin C isoform is not useful in the management of myocardial infarction and it is not necessary to monitor both the T and I isoform.

The quantitative test is normally performed every 8-12 hours the first 24 hours. Once the determination is made whether myocardial injury has occurred, it is expected that a Troponin level will be performed only when the results are to be used in the active treatment of the patient.

When Troponin and Creatine Kinase are used concurrently without an indication for both tests, this is considered a duplication of services and in this case, Troponin will be denied. 

 

Coverage Topic 

Lab Services
 

 

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.

 

 

 

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.

 

0301

Laboratory-chemistry

 

 

CPT/HCPCS Codes 

 

84484

TROPONIN, QUANTITATIVE

84512

TROPONIN, QUALITATIVE

 

 

ICD-9 Codes that Support Medical Necessity 

 

410.00 - 410.92

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.1

INTERMEDIATE CORONARY SYNDROME

413.0 - 413.9

ANGINA DECUBITUS - OTHER AND UNSPECIFIED ANGINA PECTORIS

427.0 - 427.9

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - CARDIAC DYSRHYTHMIA UNSPECIFIED

785.0

TACHYCARDIA UNSPECIFIED

786.03 - 786.09

APNEA - RESPIRATORY ABNORMALITY OTHER

786.50 - 786.59

UNSPECIFIED CHEST PAIN - OTHER CHEST PAIN

794.31

NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

1. The medical records must document the medical necessity of the test including the test results. This information is usually found in the office/progress notes, emergency/hospital notes, and/or laboratory results.

2. If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the studies. The physician must state the clinical indication/medical necessity for the study in his order for the test. 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Adams III, Schechtman, K., Landt, Y., Ladenson, J., & Jaffe, A. (1994). Comparable Detection of Acute Myocardial Infarction by Creatine Kinase MB Isoenzyme and Cardiac Troponin I. Clinical Chemistry, 40 (7), 1291-1295.

Antman, E., Tanasijevic, M., Thompson, B., et al. (1996). Cardiac-specific Troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. The New England Journal of Medicine, 335 (18), 1342-1349.

Braunwald, E. (1992). Heart Disease: A Textbook of Cardiovascular Medicine. (4th ed.). Philadelphia: W. B. Saunders Company.

Guest, T., Ramanathan, A., Tuteur, P., Schechtman, K., Labenson, J., & Jaffe, A. (1995). Myocardial injury in critically ill patients. Journal of the American Medical Association,273 (24), 1945-1949.

Hamm, C., Goldmann, B., Heeschen, C., Kreymann, G., Berger, J., & Meinertz, T. (1997). Emergency Room triage of patients with acute chest pain by means of rapid testing for Cardiac Troponin I or Troponin T. The New England Journal of Medicine, 337 (23), 1648-1653.

Jacobs, D., DeMott, W., Finley, P., Horvak, R., Kasten, B., & Tilzer, L. (1994). Laboratory Test Handbook (3rd ed.). Hudson: Lexi-Comp Inc.

Jaffe, A., Landt, Y., Parvin, C., Abendschein, D., Geltman, E., & Ladenson, J. (1996). Comparative sensitivity of cardiac troponin I and lactate dehydrogenase isoenzymes for diagnosing acute myocardial infarction. Clinical Chemistry, 42 (11), 1770-1776.

Keffer, J. (1997). The cardiac profile and proposed practice guideline for acute ischemic heart disease. Clinical Chemistry, 107 (4), 398-409.

Lindahl, B., Venge, P., & Wallentin, L. (1997). Troponin I identifies patients with unstable Coronary Artery Disease who benefit from long-term antithrombotic protection. Journal of the American College of Cardiology, 29 (1), 43-48.

Mair, J. (1997). Cardiac troponin I and troponin T: Are enzymes still relevant as cardiac markers? Clinica Chimica Acta, 99-115.

Martins, J., Li, D., Baskin, L., Jialal, I., & Kepper, J. (1996). Comparison of Cardiac Troponin I and Lactate Dehydrogenase Isoenzymes for the late diagnosis of myocardial injury. Clinical Chemistry, 106 (6), 705-708.

Ohman, E., Armstrong, P., Christenson, R., et al. (1996). Cardiac Troponin T levels for risk stratification in acute myocardial ischemia. The New England Journal of Medicine, 335 (18), 1333-1341.

Willerson, J. T. (1995). Cardiovascular Medicine. New York: Churchill Livingstone. 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from Cardiac and Emergency Medicine. 

 

Start Date of Comment Period 

07/12/2000 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

08/28/2000 

 

Revision History Number 

1686a 

 

Revision History Explanation 

07/24/2002 Formatted

05/17/2001 expanded MR&N guidelines for Troponin as an adjunct to CPK
04/10/2001 updated interpretation of HCFA National Coverage Policy

12/08/2000 ICD-9 & CPT code check with the code books, no changes made.

This LCD was converted from an LMRP on 12/8/2005

10/30/2007 - Frequently Asked Questions restored to Appendices 

 

Reason for Change 

 

Last Reviewed On Date 

10/30/2007 

 

Related Documents 

Article(s)
A37939 - Troponin

 

LCD Attachments 

FAQ - Comment and Response (3,660 bytes)

 

Other Versions 

Updated on 09/05/2006 with effective dates 12/09/2005 - N/A

Updated on 05/31/2006 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 12/09/2005 - N/A

Updated on 12/08/2005 with effective dates 07/24/2002 - 12/08/2005

Updated on 03/11/2003 with effective dates 07/24/2002 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - N/A