Article - Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography (A57184)

CMS National Coverage PolicyTitle XVIII of the Social Security Act (SSA), 1862(a)(1)(A), states that no Medicare payment shall be made for 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, 1862(a)(7) and 42 Code of Federal Regulations, Section 411.15, exclude routine physical examinations.Title XVIII of the Social Security Act, 1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 50-50.4, and CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 20.4.4, allows for a separate payment for the supply of a radiopharmaceutical diagnostic imaging agent and/or pharmacologic stressing agent with diagnostic nuclear medicine procedures.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 50. This section specifies coverage for drugs and biologicals.CMS Manual System, Pub. 100-03,Medicare National Coverage Determinations Manual,Chapter 1, 20.10; Supplies, regarding pharmaceutic stressing agents. (Repealed 02/22/2010,see Pub. 100-04, Ch. 32, 140.)The Code of Federal Regulations (CFR), 42 CFR 410.32, specifies that all diagnostic tests must be ordered by the physician who is treating the beneficiary.Section 4317(b), of the Balanced Budget Act (BBA) of 1997, specifies that referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80.6.1; Requirements for Ordering and Following Orders for Diagnostic Tests and Definitions.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 12, 30.6.6.B, clarifies coverage for preoperative evaluations.CMS Manual System, Pub. 100-04,Medicare Claims Processing Manual,Chapter 13, 20, 20.1, 20.2, 20.2.2, 20.2.3, 20.3.1 and 20.3.2; Payment conditions for Radiology Services.CMS Manual System, Pub. 100-02,Medicare Benefit Policy Manual,Chapter 15, 80, Requirements for Diagnostic X-Ray, Diagnostic Laboratory and other Diagnostic Tests sets forth the various levels of physician supervision required for diagnostic tests.CMS Manual System, Pub.100.04,Medicare Claims Processing Manual,Chapter 32, 140.1, 140.1.1, 140.2, 140.2.2.1, 140.2.2.3, 140.2.2.4, 140.2.2.5, 140.2.2.6, 140.3, 140.3.1., Cardiac Rehabilitation.Article TextThe following coding and billing guidance is to be used with its associated Local coverage determination.Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request.Documentation in the patients medical record must substantiate the medical necessity of the service, including the following: A clinical diagnosis, The specific reason for the study, Reason for performing a stress echocardiogram as opposed to only an electrical stress test, The reason for using any pharmacological stress, and The reason for a stress echocardiogram if a stress nuclear test is also performed for the same patient for the same clinical condition.Document the referral order (written or verbal) in the patients medical record. For example, if a referring physician calls a cardiologist to order a stress echocardiogram, the test report or office record must document the date of the call, name of the referring physician, and reason for referral.Document the interpretation and report of all segments of the service (e.g., the electrical and echo results).Document the necessity for the test frequency, when applicable.Document (preferably on the test report) that any applicable physician supervision requirement is met.For tests performed by leased employees, maintain the leasing contract on file (e.g., in the office) and submit it to the contractor for review upon request.Utilization Guidelines:Stress testing is covered only at a frequency appropriate for the patients condition, and when the results will potentially affect the patients treatment.A routine follow-up test after an MI, CABG, or PTCA, in the absence of symptoms or clinical indications, outside of the reassessment period, is not reasonable and necessary. Annual testing in the absence of individualized clinical indications is not reasonable and necessary. For example, a patient who has had a MI, CABG, PTCA, or other coronary revascularization procedure may require an initial follow-up stress test several months later and a second test one year after the first follow-up test. Thereafter, a patient who initially presented with silent coronary disease (no reliable signs or symptoms) may require testing as often as annually. However, a patient who initially presented with reliable symptoms or signs of CAD (e.g., angina pectoris) typically will not need annual testing. When the clinical information is sufficient to reliably monitor the patient, an additional follow-up test once every five years may be sufficient.