0111-Transthoracic Echocardiography: Medical Necessity and Documentation Requirements

Issue Name
0111-Transthoracic Echocardiography: Medical Necessity and Documentation Requirements
Date
Review Type
Complex
Provider Type
Inpatient Hospital; Outpatient Hospital; Skilled Nursing Facility (SNF)
MAC Jurisdiction
All A/B MACs

Description

Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary.

Affected Code(s)

For CGS, First Coast and NGS: 93303, 93306, 93307, C8921, C8923

Applicable Policy References

1.    Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
2.    Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A); (a)(7)- Exclusions from Coverage and Medicare as a Secondary Payer
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 Code of Federal Regulations §405.986 - Good Cause for Reopening
7.    42 Code of Federal Regulations §410.32(a) - Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
8.    42 Code of Federal Regulations §411.15(k)(1) - Particular Services Excluded from Coverage
9.    Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests
10.    Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.4- Cardiovascular System (Codes 92950- 93799)
11.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
12.    CGS LCD L34338- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/06/2022
13.    First Coast LCD L33768- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019
14.    NGS LCD L33577- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019
15.    Palmetto LCD L37379- Echocardiography; Effective 9/18/2017; Revised -06/10/2021
16.    CGS LCA A57306- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 9/26/2019; Revised 10/01/2022
17.    First Coast LCA A57182- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 10/03/2018; Revised 10/01/2022
18.    NGS LCA A56781- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 8/01/2019; Revised 10/01/2022
19.    Palmetto LCA A56625- Billing and Coding:  Echocardiography; Effective 06/20/2019; Revised 10/01/2022
20.    American Medical Association (AMA), Current Procedural Terminology Manual, Coding Guidelines