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Last Modified: 2/3/2021 Location: FL, PR, USVI Business: Part A, Part B

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

On January 24, 2020, First Coast Service Options published local coverage determination (LCD) L38396 Cardiology Non-emergent Outpatient Stress Testing external link, which became effective for dates of service on and after March 15, 2020. The new LCD also has a 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.


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.


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, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to the LCD for reasonable and necessary requirements and limitations.
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.