CPT/HCPCS Codes Group 1 Codes:
75572 Ct hrt w/3d image
75573 Ct hrt w/3d image congen
75574 Ct angio hrt w/3d image
Group 2 Codes:
75571 Ct hrt w/o dye w/ca test
Coverage Indications, Limitations, and/or Medical Necessity
As an alternative to invasive coronary angiography following a stress test that is equivocal or suspected to be inaccurate.
Instead of myocardial perfusion imaging in the evaluation of coronary artery disease in those patients who have moderate pre-test probability of disease based on clinical risk factors and abnormal diagnostic studies, not symptoms alone.
To evaluate the cause of symptoms in patients with known coronary artery disease.
Assessment of suspected congenital anomalies of coronary circulation or great vessels.
Assessment of coronary or pulmonary venous anatomy for the procedures described below:
CTA of the coronary veins is indicated when imaging of the coronary venous anatomy is necessary for biventricular pacemaker lead insertion.
CTA of the pulmonary veins is indicated when imaging of the pulmonary vasculature is necessary for pulmonary vein catheter ablation procedures for atrial fibrillation.
Since the majority of the clinical research utilized a 64-slice CT scanner it is the recommended equipment. However, the intent of this LCD is not to monitor equipment utilization.
The procedure must be performed under the direct supervision of and interpreted by a cardiologist or radiologist who meets the competency guidelines outlined by the published guidelines, ACCF/AHA Clinical Competence Statement on Cardiac Imaging with Computed Tomography and Magnetic Resonance, or American College of Radiology Clinical Statement on Noninvasive Cardiac Imaging.
Using 71275 or 76497
Screening tests are defined as those tests done in the absence of signs, symptoms, or presence of disease. The use of these procedures (75572, 75573, 75574 for coronary CT angiography) in patients without signs, symptoms or presence of disease is considered to be screening by this Contractor.
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.
999x Not Applicable
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.
99999 Not Applicable
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
I20.1 – I20.9 – Opens in a new window Angina pectoris with documented spasm – Angina pectoris, unspecified
I25.10 – I25.119 – Opens in a new window Atherosclerotic heart disease of native coronary artery without angina pectoris – Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.41 – I25.739 – Opens in a new window Coronary artery aneurysm – Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.751 – I25.759 – Opens in a new window Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm – Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.761 – I25.810 – Opens in a new window Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm – Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 – I25.9 – Opens in a new window Chronic total occlusion of coronary artery – Chronic ischemic heart disease, unspecified
I48.0 – I48.92 – Opens in a new window Paroxysmal atrial fibrillation – Unspecified atrial flutter
Q20.0 – Q25.0 – Opens in a new window Common arterial trunk – Patent ductus arteriosus
Q25.3 – Q26.4 – Opens in a new window Supravalvular aortic stenosis – Anomalous pulmonary venous connection, unspecified
Q26.8 Other congenital malformations of great veins
R06.02 Shortness of breath
R07.2 Precordial pain
R94.30 – R94.39 – Opens in a new window Abnormal result of cardiovascular function study, unspecified – Abnormal result of other cardiovascular function study
Z01.810 Encounter for preprocedural cardiovascular examination
MDCT angiography of the chest for non-cardiac assessment (71275) will be considered medically reasonable and necessary for the following signs or symptoms of disease:
• Assessment of a symptomatic patient when presentation is suspicious for pulmonary emboli;
• Abnormalities of the thoracic vasculature such as aortic dissection, aortic aneurysm, pulmonary arterio- venous malformation (AVM) and other abnormalities of the systemic circulation, excluding the heart;
• Assessment of suspected congenital anomalies of the heart or great vessels; and
• Assessment of cardiac, mediastinal or lung parenchymal lesions, the vascularity of which is unknown or ill defined, but is critical to the diagnosis.
MDCT angiography of the chest for cardiac assessment will be considered medically reasonable and necessary for the following signs or symptoms of disease:
• Cardiac evaluation of a patient with chest pain syndrome (e.g. anginal equivalent, angina), who is at a low to moderate risk for coronary artery disease (CAD), if use of MDCT is expected to avoid performing diagnostic cardiac catheterization. MDCT and coronary angiography are not expected to be performed on the same patient for diagnostic purposes prior to the application of anticipated therapy. (If a high pretest probability of disease exists, as if the patient has known CAD, it is assumed the patient would go to coronary angiography as the definitive test, where possible angioplasty and/or stenting could be performed at the same time).
• Assessment of suspected congenital anomalies of coronary circulation.
• Assessment of symptomatic patients with equivocal stress test results, with or without cardiac imaging,if MDCT is expected to avoid performing diagnostic coronary angiography. (Again, if a high pre-test probability of disease exists, as if the patient has known CAD, it is not expected that CT coronary
angiography would be done in addition to a subsequent coronary catheterization and angiogram).
• Evaluation of pulmonary veins prior to arrhythmia ablation procedures
• Evaluation of cardiac veins prior to insertion of biventricular pacemaker Additionally, at times, it may be necessary to evaluate the patient for both cardiac and noncardiac disease.
Pending the assignment of a code that more precisely describes this service, protocols using cardiovascular CT angiography for the evaluation of acute chest pain in the emergency setting, where pulmonary and/or aortic vascular etiology are also a concern, must be coded with CPT code 71275 only. Billing CPT code 71275 plus one of the following CPT codes (75571, 75572, 75573, or 75574) would attest to the fact that two completely separate procedures were performed in their entirety.
• The test is never covered for screening, i.e., in the absence of signs, symptoms or disease.
• The test is never covered for patients with stable coronary artery disease without any significant change in signs or symptoms.
• The selection of the test should be made within the context of other testing modalities so that the resulting information facilitates the management decision, and does not merely add an additional layer of testing. The test may be denied, on post-pay review, as not medically necessary when used for cardiac evaluation of a patient with extensive disease where there is a pre-test knowledge of extensive calcification that would diminish the interpretive value.
• Coverage of this modality for coronary artery assessment is limited to devices that process thin, highresolution slices (0.75 mm or less) A multidetector scanner must have a row of at least 32 detectors. For non-cardiac thoracic assessment, the multidetector scanner may have a capability of less than 16 slices or less. The rotational gantry speeds for cardiac evaluation must be 420 milliseconds or less.
• The administration of beta-blockers and/or other medications and the monitoring of the patient by a physician during the MDCT are not separately payable services.
• All studies must be ordered by a physician or a qualified non-physician practitioner. A physician or qualified non-physician provider must be present during testing whenever cardioactive agents or contrast agents are administered (direct physician supervision). Ideally, this supervising physician will be experienced in this procedure and ACLS-certified.
• Electron Beam Technology provides high temporal resolution and enables quantitative assessment of the coronary artery calcium, but because of limited spatial resolution as a result of the limited z axis resolution (slice thickness=3.0 mm), it does not permit direct visualization in multi-reformation of the whole coronary system. Therefore, CT angiography of the heart is not considered medically necessary when performed with an EBT scanner.
The following codes will be considered reasonable and necessary for CT Angiography of the Chest for Cardiac indications for CPT codes 75571, 75572, 75573, 75574.