Article - Billing and Coding: Echocardiography for Myocardial Perfusion (A58503)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, 30 Services Paid Under the Medicare Physicians Fee ScheduleCMS Internet-Only Manual, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.4.1.3 Diagnosis Code RequirementsArticle TextThe information in this article contains billing, coding or other guidelines that complements the Local Coverage Determination (LCD) for Echocardiography for Myocardial Perfusion L38786.An echocardiogram done with an ultrasound enhancing agent (UEA) in the setting of cardiovascular disease for purposes of left ventricular opacification (LVO) is reasonable and medically necessary. It is the only FDA-approved use for UEAs in cardiovascular disease at the current time.All other applications in cardiovascular disease including those for myocardial perfusion measurement or myocardial viability are currently off-label uses. However, such use does occur regularly. Furthermore, over many decades a significant amount of data has accumulated and many studies, both single and multicenter in design, have been performed. The collective evidence in its totality regarding the use of UEAs approved for LVO purposes, specifically for myocardial perfusion evaluation is interpreted as warranting coverage despite off-label use.Per the related LCD, echocardiography with UEAs for purposes of assessing myocardial perfusion is considered reasonable and necessary when evaluating individuals with elevated cardiovascular risk factors in the setting of symptomatic angina with known or suspected underlying coronary artery disease (CAD). Assessment of myocardial perfusion via echocardiography with UAEs for purposes of determining cardiac viability is also considered reasonable and necessary for purposes of therapeutic or diagnostic decision making.Documentation:Regarding this topic, in general, certain documentation would be expected for the use of UEAs (aka contrast) in assessing myocardial perfusion with echocardiography procedures, to include the following:The condition/diagnosis necessitating the echocardiographic procedureThe condition/diagnosis necessitating the administration of an UEADocumentation should be available, if requested, regarding the echocardiographic methods employed including mechanical indices utilized as well as accreditation of the lab and the certification of the echocardiographer.Medical records may be requested for determination of medical necessity. Additional letters of support and/or explanation are often useful, but do not represent enough documentation unless all specific information needed to make a medical necessity determination is included.The documentation in the patients medical record must support the use of UEAs as being medically reasonable and necessary.Based on that documentation, the determination of reasonable and necessary is currently left to the discretion of the Medicare Administrative Contractors (MACs).Billing information:When ultrasound (US) contrast enhancement is used for visualizing the ventricular chambers and endocardial border, the supply is considered separate from the procedure for reimbursement from Medicare.Diagnostic injection services are an integral part of a contrast procedure and are not separately payable.