Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed, conditions. The pulmonary stress test will be considered medically necessary for these conditions:
- To determine whether the patient’s exercise intolerance is related to pulmonary disease and not cardiac disease, lack of conditioning or poor effort.
- Initial diagnostic workup, when symptoms, generally dyspnea, are out of proportion to findings on static function (spirometry, lung volume and diffusion capacity).
- Detection of interstitial lung disease (fibrosis) or exercise-induced bronchospasm, which are only manifested by exercise.
- To evaluate patient’s response to a newly established pulmonary treatment regimen.
Abnormal results on the Stage I protocol may indicate that more precise information is required through more complex Stage 2 protocols. If Stage 3 protocols are implemented, arterial blood analysis is necessary. In 75 percent of patients, Stage 1 is sufficient. To determine the oxygen needs for improving exercise tolerance and increased functional capacity, oxygen titration can be done during graded exercise. Absolute contraindications to exercise testing include:
- Acute febrile illness.
- Pulmonary edema.
- Systolic BP > 250 mm Hg.
- Diastolic BP > 120 mm Hg.
- Acute asthma attack.
- Unstable angina.
- Acute myocarditis.
Limitations:
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
11X, 12X, 13X, 21X, 22X, 23X, 71X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances, Revenue Codes are purely advisory; unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD . Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/orRevenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual Publication 100-04, Claims Processing Manual, for further guidance.
046X, 0410, 0412 and 0419
CPT/HCPCS Codes
Note:
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Providers are reminded to refer to the long descriptors of the
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94620©
|
Pulmonary stress test/simple
|
94621©
|
Pulm stress test/complex
|
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 94620 and 94621:
Covered for:
135
|
Sarcoidosis
|
162.0
|
Malignant neoplasm of trachea
|
162.2–162.5
|
Malignant neoplasm of trachea, bronchus, and lung
|
162.8–162.9
|
Malignant neoplasm of trachea, bronchus, and lung
|
197.0
|
Secondary malignant neoplasm of lung
|
197.3
|
Secondary malignant neoplasm of other respiratory organs
|
212.2–212.3
|
Benign neoplasm of respiratory and intrathoracic organs
|
231.2
|
Carcinoma in situ of bronchus and lung
|
415.0
|
Acute cor pulmonale
|
415.11–415.12
|
Pulmonary embolism and infarction
|
415.19
|
Other pulmonary embolism and infarction
|
446.20
|
Hypersensitivity angiitis, unspecified
|
466.0
|
Acute bronchitis
|
466.11
|
Acute bronchiolitis due to Respiratory Syncytial Virus (RSV)
|
466.19
|
Acute bronchiolitis due to other infectious organisms
|
490
|
Bronchitis, not specified as acute or chronic
|
491.0–491.1
|
Chronic bronchitis
|
491.20–491.22
|
Obstructive chronic bronchitis
|
491.8–491.9
|
Chronic bronchitis
|
492.0
|
Emphysematous bleb
|
492.8
|
Other emphysema
|
493.00–493.02
|
Extrinsic asthma
|
493.10–493.12
|
Intrinsic asthma
|
493.20
|
Chronic obstructive asthma, unspecified
|
493.22
|
Chronic obstructive asthma, with (acute) exacerbation
|
493.81–493.82
|
Other forms of asthma
|
493.90–493.92
|
Asthma, unspecified
|
494.0
|
Bronchiectasis, without acute exacerbation
|
495.0–495.9
|
Extrinsic allergic alveolitis
|
496
|
Chronic airway obstruction, not elsewhere classified
|
500
|
Coal worker’s pneumoconiosis
|
501
|
Asbestosis
|
502
|
Pneumoconiosis due to other silica or silicates
|
503
|
Pneumoconiosis due to inorganic dust
|
504
|
Pneumopathy due to inhalation of other dusts
|
505
|
Pneumoconiosis, unspecified
|
508.0–508.1
|
Respiratory conditions due to other and unspecified external agents
|
508.8–508.9
|
Respiratory conditions due to other and unspecified external agents
|
515
|
Postinflammatory pulmonary fibrosis
|
517.1–517.2
|
Lung involvement in conditions classified elsewhere
|
517.8
|
Lung involvement in other diseases classified elsewhere
|
518.0–518.3
|
Other diseases of lung
|
518.5–518.6
|
Other diseases of lung
|
518.81–518.84
|
Other diseases of lung
|
518.89
|
Other diseases of lung, not elsewhere classified
|
519.11
|
Acute bronchospasm
|
519.19
|
Other diseases of trachea and bronchus
|
519.4
|
Disorders of diaphragm
|
519.8
|
Other diseases of respiratory system, not elsewhere classified
|
714.81
|
Rheumatoid lung
|
737.30
|
Kyphoscoliosis and scoliosis
|
780.51
|
Insomnia with sleep apnea
|
780.53
|
Hypersomnia with sleep apnea
|
780.57
|
Other and unspecified sleep apnea
|
786.02
|
Dyspnea and respiratory abnormalities
|
786.03–786.07
|
Apnea
|
786.09
|
Other dyspnea and respiratory abnormality
|
786.2
|
Cough
|
786.30
|
Hemoptysis, unspecified
|
786.39
|
Other hemoptysis
|
793.1
|
Nonspecific (abnormal) findings on radiological and other examination of lung field
|
V72.82
|
Preoperative respiratory examination
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Medical record documentation must indicate the medical necessity for performing the test. Documentation that the service and all it components were performed, including the results of the pulmonary stress test, should be available. This information is normally found in the office notes, progress notes, history and physical, and/or hard copy of the test results.
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 interpretations, along with copies of the ordering/referring physician’s order for the studies. The physician must indicate the clinical indication/medical necessity for the study in his order for the test.
Hey I just came through your blog its really nice blog. you share some good news here on Pulmonary Edema/stress. It is a big issue today.
Pulmonary edema is often caused by congestive heart failure. When the heart is not able to pump blood to the body efficiently, it can back up into the veins that take blood through the lungs to the left side of the heart.
As the pressure in these blood vessels increases, fluid is pushed into the air spaces (alveoli) in the lungs. This fluid reduces normal oxygen movement through the lungs. This and the increased pressure can lead to shortness of breath.
Pulmonary Edema Causes