SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Thrombolytic Agents

A55237

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A55237
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Thrombolytic Agents
Article Type
Billing and Coding
Original Effective Date
08/04/2016
Revision Effective Date
05/24/2020
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

Internet-Only Manuals (IOMs)

  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 23, Section 10 Reporting ICD Diagnosis and Procedure codes

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35428 Thrombolytic Agents. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Reporting CPT code 92977

An intravenous injection or infusion of a thrombolytic agent (e.g., streptokinase) should be submitted with CPT code 92977 when the physician has personally administered it. Monitoring of the patient and associated services should be billed in accordance with the level of medical care reported.

Drug Wastage

When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted. The documentation must include the date, time, amount of medication wasted, and the reason for the wastage.

JW Modifier Requirement:

Effective 01/01/2017, per CR 9603, when billing for Part B drugs and biologicals (except those provided under CAP), the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record.

Professional Component and Technical Component Indicators (PCTC) for thrombolytic procedures:

PCTC indicators provide additional information on Professional/Technical services (applicable to Part B services). PCTC indicators are located on the CMS Physician Fee Schedule and can also be found on the Novitas website under fee schedules (from the menu or quick links). For additional information, such as a complete list of all of the PCTC descriptors, please refer to the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 50.6 Physician Fee schedule payment policy indicator file record layout.

CPT code 36593 has a PCTC indicator of a 3 (technical component only code) which identifies standalone codes that describe the technical component (such as staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only.

Note: Modifiers -26 and TC cannot be used with CPT code 36593.

CPT codes 37195 and 92977 have a PCTC indicator of a 5 (incident to codes) which identifies codes that describe services covered incident to a physician's service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision. Payment may not be made under Part B for these services when they are provided to hospital inpatients or patients in a hospital outpatient department.

Note:
Modifiers -26 and TC cannot be used with CPT code 37195 or 92977. Also note that CPT codes 37195 or 92977 are not eligible for reimbursement by Part B in a facility setting.

Consistent with the indications outlined in LCD L35428, Thrombolytic Agents, CPT codes 37195 and 92977 should be billed in Part A with one of the following Bill Types; 12X, 13X or 85X.

CPT codes 37211, 37212, 37213, 37214, 61645, and 92975 have a PCTC indicator of 0 (Physician service codes) which identifies codes that describe physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components.

Consistent with the indications outlined in LCD L35428, Thrombolytic Agents, CPT codes 37211, 37212, 37213, 37214, 61645 and 92975 should be billed in Part A with 12X Bill Type and in Part B with 21 place of service.

Note: Modifiers -26 and TC cannot be used with CPT codes 37211, 37212, 37213, 37214, 61645, or 92975.

Documentation Requirements

  1. All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
0636 Pharmacy - Drugs Requiring Detailed Coding
N/A

CPT/HCPCS Codes

Group 1

(16 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
36593 Declot vascular device
37195 Thrombolytic therapy stroke
37211 Thrombolytic art therapy
37212 Thrombolytic venous therapy
37213 Thromblytic art/ven therapy
37214 Cessj therapy cath removal
61645 Perq art m-thrombect &/nfs
92975 Dissolve clot heart vessel
92977 Dissolve clot heart vessel
J0350 Injection anistreplase 30 u
J2993 Reteplase injection
J2995 Inj streptokinase /250000 iu
J2997 Alteplase recombinant
J3101 Tenecteplase injection
J3364 Urokinase 5000 iu injection
J3365 Urokinase 250,000 iu inj
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(9 Codes)
Group 1 Paragraph

Note: It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

Please refer to the limitations section of the related LCD, L35428 Thrombolytic Agents for reasonable and necessary information related to Urokinase HCPCS code J3364.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 36593, J0350, J2993, J2995, J2997, J3101, J3364, and J3365:

Group 1 Codes
Code Description
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.818D Embolism due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.818S Embolism due to vascular prosthetic devices, implants and grafts, sequela
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.868D Thrombosis due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.868S Thrombosis due to vascular prosthetic devices, implants and grafts, sequela
Z45.2 Encounter for adjustment and management of vascular access device
Z51.11 Encounter for antineoplastic chemotherapy
Z51.12 Encounter for antineoplastic immunotherapy

Group 2

(88 Codes)
Group 2 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS codes 37195, 61645, J0350, J2993, J2995, J2997, J3101, and J3365:

Group 2 Codes
Code Description
I63.011 Cerebral infarction due to thrombosis of right vertebral artery
I63.012 Cerebral infarction due to thrombosis of left vertebral artery
I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries
I63.02 Cerebral infarction due to thrombosis of basilar artery
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.09 Cerebral infarction due to thrombosis of other precerebral artery
I63.111 Cerebral infarction due to embolism of right vertebral artery
I63.112 Cerebral infarction due to embolism of left vertebral artery
I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries
I63.12 Cerebral infarction due to embolism of basilar artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.133 Cerebral infarction due to embolism of bilateral carotid arteries
I63.19 Cerebral infarction due to embolism of other precerebral artery
I63.211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery
I63.212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery
I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar artery
I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries
I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.29 Cerebral infarction due to unspecified occlusion or stenosis of other precerebral arteries
I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery
I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries
I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery
I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery
I63.323 Cerebral infarction due to thrombosis of bilateral anterior cerebral arteries
I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery
I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery
I63.333 Cerebral infarction due to thrombosis of bilateral posterior cerebral arteries
I63.341 Cerebral infarction due to thrombosis of right cerebellar artery
I63.342 Cerebral infarction due to thrombosis of left cerebellar artery
I63.343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries
I63.39 Cerebral infarction due to thrombosis of other cerebral artery
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle cerebral artery
I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries
I63.421 Cerebral infarction due to embolism of right anterior cerebral artery
I63.422 Cerebral infarction due to embolism of left anterior cerebral artery
I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries
I63.431 Cerebral infarction due to embolism of right posterior cerebral artery
I63.432 Cerebral infarction due to embolism of left posterior cerebral artery
I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries
I63.441 Cerebral infarction due to embolism of right cerebellar artery
I63.442 Cerebral infarction due to embolism of left cerebellar artery
I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries
I63.49 Cerebral infarction due to embolism of other cerebral artery
I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery
I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery
I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries
I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery
I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery
I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries
I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery
I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery
I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries
I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery
I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery
I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries
I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
I65.01 Occlusion and stenosis of right vertebral artery
I65.02 Occlusion and stenosis of left vertebral artery
I65.03 Occlusion and stenosis of bilateral vertebral arteries
I65.1 Occlusion and stenosis of basilar artery
I65.21 Occlusion and stenosis of right carotid artery
I65.22 Occlusion and stenosis of left carotid artery
I65.23 Occlusion and stenosis of bilateral carotid arteries
I65.8 Occlusion and stenosis of other precerebral arteries
I65.9 Occlusion and stenosis of unspecified precerebral artery
I66.01 Occlusion and stenosis of right middle cerebral artery
I66.02 Occlusion and stenosis of left middle cerebral artery
I66.03 Occlusion and stenosis of bilateral middle cerebral arteries
I66.11 Occlusion and stenosis of right anterior cerebral artery
I66.12 Occlusion and stenosis of left anterior cerebral artery
I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21 Occlusion and stenosis of right posterior cerebral artery
I66.22 Occlusion and stenosis of left posterior cerebral artery
I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries
I66.29 Occlusion and stenosis of unspecified posterior cerebral artery
I66.3 Occlusion and stenosis of cerebellar arteries
I66.8 Occlusion and stenosis of other cerebral arteries
I66.9 Occlusion and stenosis of unspecified cerebral artery
I67.81 Acute cerebrovascular insufficiency
I67.82 Cerebral ischemia
I67.89 Other cerebrovascular disease

Group 3

(31 Codes)
Group 3 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS codes 37211*, 37213*, 37214*, J0350, J2993, J2995, J2997, J3101, and J3365:

*Note: additional coverage for CPT codes 37211, 37213 and 37214 is located in the Group 4 Codes section.

Covered for:

Group 3 Codes
Code Description
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.51 Other specified diabetes mellitus with diabetic peripheral angiopathy without gangrene
E13.52 Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
I74.01 Saddle embolus of abdominal aorta
I74.09 Other arterial embolism and thrombosis of abdominal aorta
I74.11 Embolism and thrombosis of thoracic aorta
I74.2 Embolism and thrombosis of arteries of the upper extremities
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
I74.8 Embolism and thrombosis of other arteries
I75.011 Atheroembolism of right upper extremity
I75.012 Atheroembolism of left upper extremity
I75.013 Atheroembolism of bilateral upper extremities
I75.021 Atheroembolism of right lower extremity
I75.022 Atheroembolism of left lower extremity
I75.023 Atheroembolism of bilateral lower extremities
I75.81 Atheroembolism of kidney
I75.89 Atheroembolism of other site
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.818D Embolism due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.818S Embolism due to vascular prosthetic devices, implants and grafts, sequela
T82.868A Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter
T82.868D Thrombosis due to vascular prosthetic devices, implants and grafts, subsequent encounter
T82.868S Thrombosis due to vascular prosthetic devices, implants and grafts, sequela

Group 4

(17 Codes)
Group 4 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS codes 37211*, 37212, 37213*, 37214*, J0350, J2993, J2995, J2997, J3101, and J3365:

*Note: additional coverage for CPT codes 37211, 37213 and 37214 is located in the Group 3 Codes section.

Covered for:

Group 4 Codes
Code Description
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93 Single subsegmental pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental pulmonary emboli without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I82.0 Budd-Chiari syndrome
I82.220 Acute embolism and thrombosis of inferior vena cava
I82.411 Acute embolism and thrombosis of right femoral vein
I82.412 Acute embolism and thrombosis of left femoral vein
I82.413 Acute embolism and thrombosis of femoral vein, bilateral
I82.421 Acute embolism and thrombosis of right iliac vein
I82.422 Acute embolism and thrombosis of left iliac vein
I82.423 Acute embolism and thrombosis of iliac vein, bilateral
I87.1 Compression of vein
T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter

Group 5

(11 Codes)
Group 5 Paragraph

Medicare is establishing the following limited coverage for CPT/HCPCS codes 92975, 92977, J0350, J2993, J2995, J2997, J3101, and J3365:

Covered for:

Group 5 Codes
Code Description
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All those not listed under the "ICD-10 Codes that Support Medical Necessity" section of this article.

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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 article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
085x Critical Access Hospital
N/A

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 article, 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 article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this Article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue 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 (IOM) Publication 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description
0636 Pharmacy - Drugs Requiring Detailed Coding
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
05/24/2020 R5

Billing and coding article revised and published on 05/21/2020 effective for dates of service on and after 05/24/2020. ICD-10 code T82.868S has been added to Group 1 of the ICD-10 Codes that Support Medical Necessity.

05/24/2020 R4

Future billing and coding article related to L35428, Thrombolytic Agents published on 4/9/2020 and will become effective 5/24/2020. The following have been added to the ICD-10 Code Group 3 Codes: T82.818A - T82.818S  and T82.868A - T82.868S. Standard language and format changes have been made throughout the article.

10/01/2019 R3

Article revised and published on 10/17/2019 effective for dates of service on and after 10/01/2019 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to ICD-10 Code Group 4 of the Article: I26.93 and I26.94. Please note: System changes have been made to our articles in response to CMS Change Request 10901. The Coding Section has been reordered and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

04/25/2019 R2

Article revised and published on 04/25/2019. Consistent with CMS Change Request (CR) 10868, references to the National Correct Coding guidelines were revised to reference NCCI rather than CCI. Consistent with CMS CR 10901, the CPT and ICD-10 codes along with billing and coding information has been removed from the related LCD and added to the article.

01/01/2017 R1 Article revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017. Added information on drug wastage and reporting the JW modifier per CR 9603 effective 01/01/2017.
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L35428 - Thrombolytic Agents
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Updated On Effective Dates Status
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Keywords

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