SUBJECT: TRANSTHORACIC ECHOCARDIOGRAPHY (TTE), RMP

POLICY NUMBER:

DESCRIPTION :

Transthoracic echocardiography (TTE) affords unique insight into cardiac structure and function. Two dimensional imaging (2D) defines the configuration and changing dimensions of the chambers; dynamic cyclic variation in myocardial thickness; and the associated valvular motions throughout the cardiac cycle. Superimposition of Doppler velocity recordings (with volumetric flow calculations) provides an integrated picture of cardiac structure, function, and adaptation to both normal and abnormal physiology. The proximal great vessels and the pericardium can also be directly visualized.

The plethora of structural and functional information provided by TTE is unique among diagnostic testing modalities. The rapid and noninvasive acquisition of this information has contributed to exponential application; and to potential over utilization. The National Claims History database attests to the growth of the application of TTE. In 1994 TTE (4 of 7333 CPT codes) accounted for 0.5% ($851 million) of the total Medicare expenditure of $162 billion. This policy addresses the medically necessary and appropriate application of TTE. Transesophageal echocardiography (TEE) is the subject of a separate policy statement.

POLICY TYPE: Recommended Model Local Medical Review Policy

HCPCS SECTION

& BENEFIT CATEGORY: Medicine; Cardiovascular

HCPCS CODES:© 93307, 93308, 93320, 93321, 93325

HCFA'S NATIONAL POLICY:

- Title XVIII of the Social Security Act, section 1862 (a) (7). This excludes routine physical examinations.

- Tile XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

INDICATIONS & LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:

Ventricular Function and Cardiomyopathies

Changes in myocardial thickness (hypertrophy and thinning), derived parameters of contractility, and in chamber volume and morphology can be quantified and charted over time by TTE. Cardiac responses to volume perturbations, chronic pressure excess and therapeutic interventions can be monitored. Recognition of the relative contributions of myocardial and valvular functional perturbations to a clinical presentation is facilitated. TTE aids the recognition of myopathies and their classification into hypertrophic, dilated and restrictive types. Absent clinically documented, discrete (abrupt change in signs and symptoms) episodes of deterioration, it is not generally medically necessary to augment clinical assessments with TTE measurements at more frequent than annual examinations.

Although TTE is used in the assessment of ventricular diastolic function, reproducible pathognomonic findings are not well established. In individuals with signs and/or symptoms suggestive of ventricular dysfunction, the demonstration by TTE of normal systolic function and/or ventricular hypertrophy may suggest the presence of diastolic functional abnormalities. Because the TTE findings suggesting diastolic dysfunction are less well established, this application of TTE will be expected to be confined to examiners with published peer review recognition of expertise in ventricular diastolic functional assessment and treatment.

Hypertensive Cardiovascular Disease

Left ventricular hypertrophy (LVH) correlates with prognosis in hypertensive cardiovascular disease. Certain antihypertensive medications have been reported to stabilize and possibly contribute to the regression of left ventricular hypertrophy and the insidiously progressive development of left ventricular dysfunction and dilatation. In young individuals and in individuals with borderline hypertension, the decision to commit to long-term antihypertensive therapy may be determined by the presence of left ventricular hypertrophy. TTE (CPT 93308) may assist in the decision to treat and in the formulation of a treatment program. Baseline TTE (CPT 93308) and periodic serial assessment (no more frequently than annually) would be medically appropriate. More frequent assessment should have explicit contemporaneous medical necessity documentation.

Acute Myocardial Infarction and Coronary Insufficiency

TTE can detect ischemic and infarcted myocardium. Regional motion, systolic thickening perturbations and mural thinning can be quantified and global functional adaptation assessed. The relative contributions of right ventricular ischemia and/or infarction can be evaluated. Complications of acute infarction (mural thrombi, papillary muscle dysfunction and rupture, septal defects, true or false aneurysm and myocardial rupture) can be diagnosed and their contribution to the overall clinical status placed in perspective. Following an initial TTE in the setting of acute infarction, repetition frequency will typically be dictated by the acute clinical course. Absent clinical deterioration or unclear examination findings, repeat assessment typically includes an evaluation at discharge. Convalescent evaluation at approximately six (6) months and annually thereafter generally provides adequate supplemental data to a thoughtful clinical evaluation. The medical record should document the medical necessity of more frequent TTE assessment.

The role for TTE in the emergency room assessment of individuals presenting with chest pain is in evolution. Absent supporting clinical findings of myocardial dysfunction, this application is considered investigational and will be subjected to medical necessity review.

Exposure to Cardiotoxic Agents (chemotherapeutic and external)

Measures of myocardial contractility, thinning and dilatation are important in the titration of therapeutic agents with known myocardial toxicity. Baseline assessment, bimonthly during and at six (6) months following therapy is generally considered medically appropriate. Following accidental exposure to known myocardial toxic agents, absent abrupt change in clinical signs and/or symptoms, annual assessment would be considered reasonably medically necessary.

Cardiac Transplant and Rejection Monitoring

TTE is an integral part of the cardiac donor selection and donor recipient matching process. Evaluations focus on analysis of ventricular function and the integrity of valvular performance. TTE is also incorporated into the management of allograft recipients. Myocardial thickness, retractile properties, contractile patterns and indices, restrictive hemodynamics, and the late development of pericardial fluid may alert to a rejection episode. None of these findings has achieved diagnostic sensitivity or specificity. Typically, TTE is performed weekly for the first four to eight (4-8) weeks following transplant with decremental frequency subsequently. Absent acute rejection episodes, approximately three (3) TTE examinations are typically performed yearly in chronic transplant recipients. TTE of cardiac allografts will most appropriately be performed at transplant centers by examines with unique expertise in the management of cardiac allograft recipients. Others will be expected to provide appropriate medical necessity documentation.

Native Valvular Heart Disease

Detection of mitral stenosis was among the first practical clinical applications of TTE. TTE is well established as a technique of primary choice for the evaluation of valvular pathology and its effect upon global myocardial function. The relative severity of multi valve pathologies can be quantified. Visualization of the valve and valvular apparatus facilitates therapeutic decisions when competing therapeutic options exist; especially interventions for mitral stenosis. Absent acute intervention, or a discrete change in otherwise stable clinical signs and symptoms, TTE in chronic valvular disease is used to document course over time. Generally it is not necessary to repeat these examinations more frequently than annually.

Prosthetic Heart Valves (Mechanical & Bio-prostheses)

TTE assessment soon after prosthetic valve implant is important in establishing a baseline structural and hemodynamic profile unique to the individual and the prosthesis. Size, position, underlying ventricular function and concomitant valve pathologies all impact this unique profile.

Reassessment following convalescence (3-6 months) is appropriate. Thereafter, absent discretely defined clinical events or obvious change in physical examination findings, annual stability assessment is considered medically reasonable and appropriate.

Acute Endocarditis

TTE can provide diagnostic information; larger vegetations may be directly visualized, valvular anatomy, and ventricular function directly assessed. The complications or sequelae of acute infective endocarditis can be detected and monitored over time. Acutely, examination frequency is dictated by the individual clinical course. When the acute process has been stabilized, the frequency of serial TTE evaluation will be dictated by the residual pathophysiology and discrete clinical events; analogous to the serial assessment of chronic valvular dysfunction and/or normally functioning prosthetic valves. (vide supra)

Pericardial Disease

Detection, and quantitation of the amount, of pericardial effusion were among the first and remains an important application of TTE. Pericardial fluid accumulations of as little as twenty (20) milliliters have been reliably diagnosed by TTE. Cardiac motion and blood flow patterns demonstrated by TTE characterize the hemodynamic consequences of pericardial fluid accumulation. A collage of TTE findings have been found to be reliable indices of cardiac tamponade. TTE can be a valuable adjunct during the removal of pericardial fluid and creation of pericardial windows by balloon techniques. Acutely, clinical status will dictate examination frequency. Absent acute pathophysiology, serial assessment of chronic stable pericardial effusion by TTE is not usually medically necessary. TTE is less reliable in the detection of chronic pericardial constriction. Current echocardiographic findings in constrictive pericarditis lack the necessary specificity and sensitivity to be reliable diagnostic aids.

Aortic Pathology

TTE can provide valuable information when acute or chronic aortic pathology is present. However, the posterior window of TEE, coupled with the more posterior position of the thoracic aorta has rendered TEE a more determinative study. Noninvasive TTE remains the study of choice for following chronic aortic pathology when images suitable for serial quantitation can be obtained. Repetition frequency should be guided by the pathophysiologic milieu.

Congenital Heart Disease

In children and small adults TTE provides accurate anatomic definition of most congenital heart diseases. Coupled with Doppler hemodynamic measurements, TTE usually provides accurate diagnosis and noninvasive serial assessment. A technically adequate TTE can obviate the need for preoperative catheterization in select individuals. When the disease process and therapy are stable, serial assessment by TTE requires contemporaneous medical necessity documentation, if the frequency exceeds an annual evaluation.

Suspected Cardiac Thrombi and Embolic Sources

TTE is particularly sensitive in the detection of ventricular thrombi and potentially emboli material. Limited visualization of atrial interstices and the more peripheral and superior portion of the atria render TTE less sensitive than TEE in the detection of atrial thrombus and potential embolic material. In individuals with cardiac pathology associated with a high incidence of thromboembolic (valvular heart disease, arrhythmias,-especially atrial fibrillation cardiomyopathies and ventricular dysfunction), TTE usually provides adequate supplements therapeutic decisional data. In those instances where the precise diagnosis and localization of potentially embolic material is of paramount therapeutic importance (e.g. younger stroke patients, generally < 45 year old) and the information so obtained will potentially and substantively alter therapy, or the risk of anticoagulants is inordinately high, consideration should be given to TEE if TTE provides inadequate decisional information. It merits emphasis that a negative examination (TTE or TEE) does not exclude a cardiac embolus and the finding of thrombus or vegetation does not establish a cardiac embolic source. Absent the definition of, and serial assessment for regression of, potentially embolic material, repeat examinations are not generally medically required to direct clinical decisions.

Cardiac Tumors and Masses

Infiltrative and ventricular tumors and masses can be their indent quantified and their hemodynamic consequences assessed by TTE. Right atrial space occupying masses are usually well visualized by TTE. TEE provides a more detailed view of the left atrium and is more sensitive in quantifying mass characteristics (solid, cystic, etc.) extensions and attachments. These acute pathologies are not typically followed serially.

Critically III and Trauma Patients

There is a role for echocardiography in the management of critically ill patients and trauma victims. The cause of a persistent fever may be elucidated. The diagnosis of suspect aortic or central pulmonary pathology, cardiac contusion, or a pericardial effusion may be confirmed. Perturbations of volume status may be more completely defined and management strategies modified. The frequency of these typically acute studies will be dictated by the exigencies of the clinical milieu.

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Ventricular Function and Cardiomyopathies:

(applicable to CPT codes: 9330 7, 93308, 93320, 93321, 93325)

074.23, 086.0, 088.81, 093.82, 130.3, 135, 275.0, 277.3, 391.2, 391.8, 392.0, 398.0, 398.91, 414.8, 415.0, 415.11, 416.0, 416.8, 422.0, 422.91, 422.92, 422.93, 425.0-425.5, 425.7- 425.8, 427.31 (05/02/1999), 428.0- 428.1, 429.0- 429.4, 429.81, 446.1, 674.82, 674.84, 710.0, 990

Hypertensive Cardiovascular Disease:

(applicable to CPT code: 93308)

401.0, 402.00, 402.10, 402.90, 404.00, 404.10, 404.90, 405.01

Acute Myocardial Infarction and Coronary Insufficiency

(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)

410.00-410.02, 410.10-410.12, 410.20-410.22, 410.30-410.32, 410.40-410.42, 410.50-410.52, 410.60-410.62, 410.70-410.72, 410.80-410.82, 411.0-411.1, 411.81, 411.89, 412, 413.0-413.1, 413.9, 414.00-414.03, 414.10-414.11, 414.19, 429.5-429.6, 429.71, 429.79, 446.1

Exposure to Cardiotoxic Agents
(applicable to CPT codes: 93307, 93308, 93320, 93321)
422.93, 960.7, 962.0, 963.1, 965.09, 980.3, 986, 990, 994.0, 994.8

Cardiac Transplant and Rejection Monitoring
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
962.0, 963.1, 996.83, V42.1, V59.8

Native Valvular Heart Disease
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
093.21-093.24, 391.1, 391.8, 392.0, 394.0-394.2, 395.0-395.2, 396.0-396.3, 396.8, 397.0-397.1, 424.0-424.3, 429.5-429.6, 429.81, 710.0, 785.2-785.3, 759.82

Prosthetic Heart Valves
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
996.02, 996.61, 996.71, V42.2, V43.3

Acute Endocarditis
(applicable to CPT codes: 93307,93308, 93320, 93321, 93325)
074.22, 098.84, 112.81, 115.04, 115.14, 391.1, 421.0, 421.1, 421.9, 422.92, 424.90, 424.91, 424.99, 790.7

Pericardial Disease
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
074.21, 093.81, 115.03, 115.13, 391.0, 393, 411.0, 420.0, 420.90-420.91, 420.99, 423.0-423.2, 423.8

Aortic Pathology
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
093.0-093.1, 440.20, 441.00-441.01, 441.03, 441.1-441.2, 441.6-441.7, 446.1, 446.7, 759.82

Congenital Heart Disease
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
745.0, 745.10-745.12, 745.19, 745.2-745.5, 745.60-745.61, 745.69, 745.7-745.9, 746.00-746.02, 746.09, 746.1-746.7, 746.81-746.85, 746.87, 746.89, 747.0, 747.10-747.11, 747.20-747.22, 747.29, 747.3, 747.40-747.42, 747.49, 759.3, 759.82

Suspected Cardiac Thrombi and Embolic Sources
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
427.31 (05/02/1999), 746.2-746.7, 746.81-746.85, 746.87, 746.89, 747.0, 747.10-747.11, 747.20-747.22, 747.29, 747.3, 747.40-747.42, 747.49, 759.3, 759.82

Suspected Cardiac Thrombi and Embolic Sources
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
424.90 (Requires additional, secondary, diagnosis denoting concomitant pathology)

Cardiac Tumors and Masses
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
164.1, 198.89, 212.7, 238.8-239.8

Critically III and Trauma Patients
(applicable to CPT codes: 93307, 93308, 93320, 93321, 93325)
276.5, 415.0, 415.11, 458.0, 518.4-518.5, 518.82, 780.6, 785.50-785.51, 785.59, 807.4, 861.01-861.03, 861.11-861.13, 901.0, 901.2, 901.41-901.42, 958.0-958.1, 958.4, 995.1, 996.01, 996.04, 997.1, 998.0, 998.5, 999.3-999.4

REASONS FOR DENIAL:

1 . Clinical scenarios deviating from those outlined in "Indications and Limitations of Coverage".
2. Inadequate medical necessity documentation.
3. Examination frequency exceeding those outlined in "Indications and Limitations of Coverage" when the contemporaneous medical record inadequately supports medical necessity.
4. Screening &/or routine interval examinations.
5. Examinations performed in tandem with, close proximity to, or alternating with diagnostic testing providing analogous information, e.g. nuclear medicine studies, MRI and CT. Patterns suggesting parallel or alternating testing will be subject to medical necessity review.
6. Submission without an ICD-9-CM as outlined in "Covered ICD-9 Codes" and without accompanying medical necessity documentation.
7. Submissions at variance with conditionals enumerated in "Coding Guidelines" and "Documentation Requirements". (vide infra)

NONCOVERED ICD-9 CODES: All others not listed in this policy as covered.

SOURCES OF INFORMATION:

- Hagan AD, DeMaria AN. Clinical Applications of Two-Dimensional Echocardiography and Cardiac Doppler, Second Edition, Little, Brown & Company, Boston, MA 1989.

- Feigenbaum H. Echocardiography. in Heart Disease A Textbook of Cardiovascular Medicine, 4th ed (Ed. Braunwald E) WB Saunders, Philadelphia, PA, 1992:64-115.

- Come PC, Lee RT, Braunwald E. Noninvasive Methods of Cardiac Examination. in Harrison's Principles of Internal Medicine, 13th ed. (Eds. Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL) McGraw-Hill, New York; 1994:967-970.

- AHA Position Statement. Cardiac Transplantation: Recipient Selection, Donor Procurement, and Medical Follow-up. Circulation 1992;86(3):1061-1079.

- Task Force 5: Complications (of cardiac transplantation). JACC 1993;22(l):41-54.

- ACC/AHA Position Statement. Guidelines for the Clinical Application of Echocardiography. JACC 1990;16(7):1505-1528.

- Local Medical Review Policies of Missouri, Louisiana, Arkansas, Kansas, Nebraska

This policy was developed in conjunction with our Medical Services Review Committee (10/97) which consist of primary care and relative specialties (LAMSRC Item 97-17).

CODING GUIDELINES:

93307 Echocardiography, real-time with image documentation (2D) with or without M-mode recording; complete
93308 follow-up or limited study
93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete
93321 follow-up or limited study
93325 Doppler color flow velocity mapping (list separately in addition to code for echocardiography 76825, 76826, 76827, 76828, 93307, 93308, 93312, 93314, 93320, 93321)

1. Submission should include an ICD-9-CM code as listed in "Covered ICD-9 Codes"; and incorporate secondary diagnoses as instructed by ICD-9-CM supplementary instructions, and where indicated in this policy.

2. Submissions with an ICD-9-CM code other than those listed as "Covered" must provide accompanying, written, medical necessity documentation.

3 . When CPT code descriptors reference extent of examination (complete, limited, follow up) comparable codes should be paired when it is medically appropriate to submit more than one CPT for a unique date of service (DOS). Deviations from this pairing should be accompanied by medical necessity documentation. (q.v. 93307 & 93320, 93308 & 93321)

4. National Correct Coding Initiative guidelines should be followed.

5. It is medically inappropriate, and contradicts CPT descriptors, to submit CPT 93307 or 93308 on the same DOS as 93350; use of any combination of these codes for the same DOS without adequate medical necessity documentation will result in denial of the entire DOS submission.

6. CPT 93014, 93041, 93307 & 93308 should not be submitted on the same DOS; these are inclusive and do not represent independently identifiable services on a common DOS.

7. "Covered ICD-9 Codes" includes certain CPT - ICD-9 code pairs. These associations must be maintained. Variances must be accompanied by medical necessity documentation for individual medical review.

DOCUMENTATION REQUIREMENTS:

1. Submissions of claims with an ICD-9-CM code other than those listed as "Covered" must provide written medical necessity documentation.

2. The available medical record should document conformity with this policy and/or support the medical necessity for deviations.

3. Use of CPT - ICD-9 code combinations at variance with those outlined in the sections "ICD-9 Codes That Support Medical Necessity" &/or "Coding Guidelines" require hard copy medical necessity documentation with the initial submission of the claim(s).

OTHER COMMENTS: Medicare Providers' News LAB97-06

©Copyright, 1995; 1996 CPT Physicians' Current Procedural Terminology, AMA.

CAC NOTES:

This policy does not reflect the sole opinion of the carrier or Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carrier Advisory Committee (09/1997), which includes representatives from all recognized specialties within the state.

START DATE OF COMMENT PERIOD: 08/28/1997

START DAT E OF NOTICE PERIOD: 11/1997

EFFECTIVE DATE: 12/15/1997

REVISION DATE:

REVISION NUMBER: