Cardiology: Avoid denials and appeals -- new dual diagnosis requirements for cardiovascular stress test procedures

Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.

To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:

Select which best describes you: Health Care Professional Person(s) with Medicare

Select your location: Florida Puerto Rico U.S. Virgin Islands

Select your line of business: Part A Part B

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright Â© 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer

Home ► Cardiology ► Cardiology: Avoid denials and appeals -- new dual diagnosis requirements for cardiovascular stress test procedures

Last Modified: 4/25/2024 Location: FL, PR, USVI Business: Part A, Part B

Cardiology: Avoid denials and appeals -- new dual diagnosis requirements for cardiovascular stress test procedures

On March 5, 2021, First Coast Service Options revised local coverage determination (LCD) L38396 Cardiology Non-emergent Outpatient Stress Testing external link

, which became effective for dates of service on and after April 25, 2021. This LCD has an associated local coverage article (LCA) for billing and coding (A56952 external link

), which contains several new dual diagnosis requirements and the Current Procedural Terminology (CPT) codes covered under the policy.

The new LCD applies to the following non-emergent outpatient cardiovascular stress testing procedures:

• Cardiovascular stress test (exercise and/or pharmacological stress)

• Echocardiography (rest and stress)

• Myocardial perfusion imaging, single photon emission computed tomography (MPI, SPECT) (rest and/or stress)

• Myocardial imaging, positron emission tomography (PET)

• Cardiac magnetic resonance imaging (MRI) with stress imaging

The billing and coding article A56952 provides billing and coding guidance for diagnosis limitations that support diagnosis to procedure code automated denials.

Issue

First Coast is receiving appeals for denials of services where the provider did not bill the required dual diagnoses, or a second diagnosis code on the original claim. Many of the appeals also didn't contain the additional diagnosis code(s).

It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the International Classification of Diseases, 10th revision with Clinical Modifications (ICD-10-CM) code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Provider action required

Providers who perform these cardiovascular stress testing procedures should familiarize themselves with the new LCD and LCA and ensure to bill claims for these procedures with the required diagnosis codes.

The new dual diagnosis requirements are based on the ICD-10-CM book coding instructions:

• For ICD-10 codes I09.8, I11.0, I13.0 and I13.2, use an additional ICD-10 code to identify the type of heart failure.

• For ICD-10 codes I12.0, I12.9, I13.0, I13.10, I13.11 and I13.2, use an additional ICD-10 code to identify the stage of chronic kidney disease.

Other dual diagnosis requirements are specific to the LCD:

• ICD-10 code I25.10 requires a second diagnosis of Z95.1, Z95.5, or Z98.61 to indicate post-percutaneous coronary intervention (PCI) or post-coronary artery bypass grafting (CABG) bypass surgery.

• ICD-10 code Z79.899 requires a second diagnosis from the T36.0X1A-T50.996S range of codes.

Refer to the billing and coding LCA A56952 external link

for the specific ICD-10 codes required. The submitted medical record must support the use of the selected ICD-10-CM code(s). Be sure to review the LCD in detail before billing the CPT codes covered by the policy.

Reminder

Services performed for any given diagnosis must meet all the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in the Centers for Medicare & Medicaid Services (CMS) payment policy manuals, and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to the LCD for reasonable and necessary requirements and limitations.

Source: LCD L38396 Cardiology Non-emergent Outpatient Stress Testing; Billing and coding LCA A56952

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.