Article - Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing (A56423)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Title XVIII of the Social Security Act, Section 1834(e)(1)(B). Claims for the technical component of advanced diagnostic imaging services.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35083 Cardiology Non-Emergent Outpatient Stress Testing. Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Current Procedural Terminology (CPT) code 78434 should be reported in conjunction with CPT code 78431 or 78492.Evaluation of the individuals left ventricular wall motion and ejection fractions are routinely performed during SPECT MPI and are included in the codes definition.Attenuation correction, when performed, is included in the MPI service.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.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.If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physicians order for the studies.The ordering physician must state the clinical indication/medical necessity for the study in the order for the test.Documentation must be maintained by the referring physician in the beneficiarys medical record that the required conditions (as indicated in the Coverage Indications, Limitations and/or Medical Necessity section of the LCD) for the stress test performed have been met.The rationale for selecting pharmacologic stress testing rather than exercise stress testing must be documented in the medical record.In the instance where regional wall motion abnormalities and ejection fraction have been assessed during the same episode of care by other testing modalities (e.g., echocardiography), the medical necessity of repeating this assessment through the use of nuclear imaging modalities must be clearly documented in the medical record.All segments of the service must have a formal interpretation and report.