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    LICENSE FOR USE OF PHYSICIANS’ CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT")


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    LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDTTM)


    End User License Agreement:

    These materials contain Current Dental Terminology (CDTTM), copyright © 2020 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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    1. Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

    2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org.

    3. Applicable Federal Acquisition Regulation Clauses (FARS)/Department of Defense Federal Acquisition Regulation supplement (DFARS) Restrictions Apply to Government Use. Please click here to see all U.S. Government Rights Provisions. opens in new window

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    LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)


    American Hospital Association Disclaimer


    The American Hospital Association ("the AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.


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    Local Coverage Determination (LCD):
    B-type Natriuretic Peptide (BNP) Testing (L34038)


    Alert: Codes have moved from LCDs to Articles! Learn more opens in new window

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    Expand/Collapse the Contractor Information section Contractor Information

    Contractor NameContract TypeContract NumberJurisdictionState(s)
    Noridian Healthcare Solutions, LLC A and B MAC02101 - MAC AJ - FAlaska
    Noridian Healthcare Solutions, LLC A and B MAC02102 - MAC BJ - FAlaska
    Noridian Healthcare Solutions, LLC A and B MAC02201 - MAC AJ - FIdaho
    Noridian Healthcare Solutions, LLC A and B MAC02202 - MAC BJ - FIdaho
    Noridian Healthcare Solutions, LLC A and B MAC02301 - MAC AJ - FOregon
    Noridian Healthcare Solutions, LLC A and B MAC02302 - MAC BJ - FOregon
    Noridian Healthcare Solutions, LLC A and B MAC02401 - MAC AJ - FWashington
    Noridian Healthcare Solutions, LLC A and B MAC02402 - MAC BJ - FWashington
    Noridian Healthcare Solutions, LLC A and B MAC03101 - MAC AJ - FArizona
    Noridian Healthcare Solutions, LLC A and B MAC03102 - MAC BJ - FArizona
    Noridian Healthcare Solutions, LLC A and B MAC03201 - MAC AJ - FMontana
    Noridian Healthcare Solutions, LLC A and B MAC03202 - MAC BJ - FMontana
    Noridian Healthcare Solutions, LLC A and B MAC03301 - MAC AJ - FNorth Dakota
    Noridian Healthcare Solutions, LLC A and B MAC03302 - MAC BJ - FNorth Dakota
    Noridian Healthcare Solutions, LLC A and B MAC03401 - MAC AJ - FSouth Dakota
    Noridian Healthcare Solutions, LLC A and B MAC03402 - MAC BJ - FSouth Dakota
    Noridian Healthcare Solutions, LLC A and B MAC03501 - MAC AJ - FUtah
    Noridian Healthcare Solutions, LLC A and B MAC03502 - MAC BJ - FUtah
    Noridian Healthcare Solutions, LLC A and B MAC03601 - MAC AJ - FWyoming
    Noridian Healthcare Solutions, LLC A and B MAC03602 - MAC BJ - FWyoming

    Expand/Collapse the browser section LCD Information

    Document Information

    LCD ID
    L34038

    LCD Title
    B-type Natriuretic Peptide (BNP) Testing

    Proposed LCD in Comment Period
    N/A

    Source Proposed LCD
    N/A

    AMA CPT / ADA CDT / AHA NUBC Copyright Statement
    CPT codes, descriptions and other data only are copyright 2020 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.

    Current Dental Terminology © 2020 American Dental Association. All rights reserved.

    Copyright © 2013 - 2020, the American Hospital Association, Chicago, Illinois. Reproduced by CMS with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Making copies or utilizing the content of the UB-04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. To license the electronic data file of UB-04 Data Specifications, contact Tim Carlson at (312) 893-6816. You may also contact us at ub04@aha.org.

    Original Effective Date
    For services performed on or after 10/01/2015

    Revision Effective Date
    For services performed on or after 10/01/2019

    Revision Ending Date
    N/A

    Retirement Date
    N/A

    Notice Period Start Date
    N/A

    Notice Period End Date
    N/A

    CMS National Coverage Policy

    Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

    Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

    Title XVIII of the Social Security Act (SSA):

    Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

    Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

    Section 1862(a)(7) excludes routine physical examinations (screening).

    Code of Federal Regulations:

    42 CFR Sections 410.32(a) & 410.32(a)(3) require that clinical laboratory services be ordered and used promptly by the physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) who is treating the beneficiary.

    42CFR411.15 excludes from coverage examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury with specific legislative enactments as the only exceptions.

    CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §§20.4.4 and 20.4.5.

    CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Chapter 9, §100 General Billing Requirements.

    CMS Manual System, Pub 100-20, One Time Notification, Transmittal 477, dated April 24, 2009, Change Request 6338.
    Coverage Guidance
    Coverage Indications, Limitations, and/or Medical Necessity

    Abstract:

    B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume expansion and pressure overload, conditions often present in congestive heart failure (CHF). Used in conjunction with other clinical information, measurement of BNP levels (either total or N-terminal) is useful in rapidly establishing or excluding the diagnosis or worsening of CHF in patients with acute exacerbation of dyspnea. Also, BNP levels determined in the first few days after an acute coronary syndrome or event (ACS) may be useful in the prediction of longer-term cardiovascular risk but this risk assessment does not change the management of ACS and is non-covered by regulation.

    Indications:

    BNP measurements may be considered reasonable and necessary when used in combination with other medical data such as medical history, physical examination, laboratory studies, and chest x-ray. 

      • to diagnose or to differentiate heart failure from other potential clinical conditions if the patient’s signs and/or symptoms are consistent with both heart failure and one or more other conditions, e.g., acute dyspnea in a patient with known or suspected pulmonary disease.
      • to diagnose or differentiate worsening heart failure if use of the test replaces other diagnostic tests, such as chest film; and/or to confirm the diagnosis when other diagnostic tests are equivocal.


     Limitations:

      • BNP measurements must be assessed in conjunction with standard diagnostic tests, medical history and clinical findings. The efficacy of BNP measurement as a stand-alone test has not been established yet.
      • BNP measurements for monitoring and management of CHF are non-covered. Treatment guided by BNP has not been shown to be superior to symptom-guided treatment in either clinical or quality-of-life outcomes.
      • The efficacy but not the utility of BNP as a risk stratification tool (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina) has been established. However, the assessment of BNP level has not been shown to alter patient management. The BNP is not sufficiently sensitive to either preclude or necessitate any other evaluation or treatment in this group of patients.
      • Screening examinations are statutorily non-covered.


    Summary of Evidence

    N/A



    Analysis of Evidence
    (Rationale for Determination)

    N/A


    Expand/Collapse the General Information section General Information

    Associated Information

    Documentation supporting medical necessity must be legible, maintained in the patient's record, and made available to the A/B MAC upon request.

    The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

    Sources of Information

    1. Alehagen U, Dahlström U, Rehfeld JF, Goetze JP. Association of copeptin and N-terminal proBNP concentrations with risk of cardiovascular death in older patients with symptoms of heart failure. JAMA. May 25 2011;305(20):2088-95. [Medline].

    2. Balion C, Don-Wauchope A, Hill S, Santaguida PL, et al. Use of natriuretic peptide measurement in the management of heart failure. Comparative Effectiveness Review No. 126 (Prepared by the McMaster University Evidence-based Practice Center under Contract No. 290-2007-1060-1.) AHRQ Publication no. 12(14)-EHC118-EF. Rockville, MD: Agency for Healthcare Research and Quality; November 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm

    3. Bayes-Genis A, de Antonio M, Galan A, et al. Combined use of high-sensitivity ST2 and NTproBNP to improve the prediction of death in heart failure. Eur J Heart Fail. Jan 2012;14(1):32-8. [Medline].

    4. Carpenter CR, Keim SM, Worster A, et al. Brain natriuretic peptide in the evaluation of emergency department dyspnea: is there a role? J Emerg Med. Nov 26 2011;[Medline].

    5. Daniels LB, Maisel AS. Natriuretic peptides. J Am Coll Cardiol. Dec 18 2007;50(25):2357-68. [Medline].

    6. DeVecchis R, Esposito C, DiBiase G, Ariano C, . et al. B-type natriuretic peptide-guided versus symptom-guided therapy in outpatients with chronic heart failure: a systematic review with meta-analysis. J Cardiovasc Med 2014; 15: 122-134.

    7. Doust J, Lehman R, Glasziou P. The Role of BNP Testing in Heart Failure. Am Fam Physician. 2006;74(11):1893-1900.

    8. Felker GM, Hasselbad V, Hernandez AF, O’Connor CM. Biomarker-guided therapy in chronic heart failure: A meta-analysis of randomized controlled trials. Am Heart J. 2009;158:422-430.

    9. Januzzi JL, van Kimmenade R, Lainchbury J, et al. NT-proBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. . 2006;27(3):330-7. [Medline].

    10.Latini R, Masson S, Wong M, et al. Incremental prognostic value of changes in B-type natriuretic peptide in heart failure. American Journal of Medicine. . 2006;119(1):70.e23-30.

    11. Le Jemtel TH, Padeletti M, Jelic S. Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J AM Coll Cardiol. 2007; 49 (2): 171–180.

    12. Li P, Luo Y, Chen Y-M. B-type Natriuretic peptide-guided chronic heart failure therapy: A meta-analysis of 11 randomized controlled trials. Heart Lung Circ. 2013;22:852-860.

    13. Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail. . Jun 2010;16(6):e1-194. [Medline].

    14. MClavel, MaloufJ, MichelenaHI, et al. B-type Natriuretic Peptide Clinical Activation in Aortic Stenosis. J Am Coll Cardiol 2014;63:2016-25

    15. Maisel AS, Mueller C, Adams K Jr, et al. State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail. . 2008;10(9):824-39.

    16. McMurray JJV. Systolic heart failure. N Engl J Med. 2010;362(3):228-238.

    17. Pfisterer M, Buser P, Rickli H, et al. BNP-guided vs. symptom-guided heart failure therapy: the Trial of Intensified vs Standard Medical Therapy in elderly patients with congestive heart failure (TIME-CHF) randomized trial. JAMA. 2009 Jan 28;301(4):383-92.

    18. Porapapkkham P, Zimmet H, Billah B, et al. B-type Natriuretic peptide-guided heart failure therapy: A meta-analysis. Arch Intern Med. . 2010;170:507-514.

    19. Ray P, Le Manach Y, Riou B. Houle T. Statistical evaluation of a biomarker. Anesthesiology. 2010; 112:1023-1040. Issue 4

    20. Saenger AK, Jaffe AS. The Use of Biomarkers for the Evaluation and Treatment of Patients with Acute Coronary Syndromes. Medical Clinics of North America. . 2007;91(4):657-681.

    21. Savarese G, Trimarco B, Dellegrottaglie S, Prastero M, et al. . Natriuretic peptide-guided therapy in chronic heart failure: A meta-analysis of 2,686 patients in 12 randomized controlled trials. PLoS One. 2013;8:e58287.

    22. Silvers SM, Howell JM, Kosowsky JM, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Heart Failure Syndromes. Ann Emerg Med. 2007;49(5):627-669.

    23. Troughton RW, Frampton AM. Biomarker-Guided Treatment of Heart Failure. Journal of the American College of Cardiology 2010; 56 (25):2101-2103.

    24. Steinhart B, Thorpe KE, Bayoumi AM, Moe G, Januzzi JL Jr, Mazer CD. Improving the diagnosis of acute heart failure using a validated prediction model. J Am Coll Cardiol. Oct 13 2009;54(16):1515-21. [Medline].

    25. Wu AH. Serial Testing of B-Type Natriuretic Peptide and NTpro-BNP for Monitoring Therapy of Heart Failure: The Role of Biologic Variation in the Interpretation of Results. American Heart Journal. 2006;152(5):828-834.

    26. Yancey CW, Jessup M, Bozkurt B, Butler J, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-e239.

    27. Yardan T, Altintop L, Baydin A, et al. B-type natriuretic peptide as an indicator of right ventricular dysfunction in acute pulmonary embolism. Int J Clin Pract. Aug 2008;62(8):1177-82. [Medline].

    Bibliography

    N/A

    Expand/Collapse the Revision History section Revision History Information

    Revision History DateRevision History NumberRevision History ExplanationReason(s) for Change
    10/01/2019 R7

    10/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage.

    LCD was converted to the "no-codes" format.
    • Revisions Due To Code Removal
    10/01/2019 R6

    10/01/2019: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage.

    The following codes were added to Group I:

    I20.0;121.01;I21.02;I21.09;I21.11;I21.19;I21.21;I21.29;I21.3;I21.4;I21.A1;I21.A9;I22.0

    I22.2;I22.8;I22.9; I25.110;I25.700;I25.710;I25.720;I25.730;I25.750;I25.760;I25.790

    R06.89;R60.1
    • Revisions Due To ICD-10-CM Code Changes
    10/01/2017 R5

    08/21/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

    LCD is revised to add the following diagnoses effective 10/01/2017:

    I50.810: Right heart failure, unspecified.

    I50.811: Acute right heart failure

    I50.812: Chronic right heart failure

    I50.813: Acute on chronic right hear failure

    I50.814: Right heart failure due to left heart failure.

    I50.82: Biventricular heart failure

    I50.83: High output heart failure

    I50.84: End state heart failure

    I50.89: Other heart failure

    R06.03: Acute Respiratory distress
    • Revisions Due To ICD-10-CM Code Changes
    11/03/2016 R4 This final LCD, effective 10/01/2016, combines JFA L34038 into the JFB LCD so that both JFA and JFB contract numbers will have the same final MCD LCD number.
    • Creation of Uniform LCDs Within a MAC Jurisdiction
    10/01/2016 R3 2016-2017 ICD 10 Update to add: I16.0 and I16.1 To Group I codes.
    • Revisions Due To ICD-10-CM Code Changes
    10/01/2015 R2 The LCD revised to add I50.9 to the ICD-10 Codes that Support Medical Necessity section effective 10/1/2015.
    • Reconsideration Request
    10/01/2015 R1 The B-type Natriuretic Peptide (BNP) Testing LCD is revised to incorporate the changes made to the same LCD policy from the JE contract after the comment period ending 03/14/2014. Updates are made only in the "CMS National Coverage Policy", "Coverage Indications, Limitations and/or Medical Necessity", "Associated Information," and " Sources of Information and Basis for Decision" sections. The effective date of the updates is 07/22/2014.
    • Provider Education/Guidance
    • Creation of Uniform LCDs Within a MAC Jurisdiction

    Expand/Collapse the Associated Documents section Associated Documents

    Attachments
    N/A
    Related Local Coverage Documents
    Article(s)
    A57084 - Billing and Coding: B-type Natriuretic Peptide (BNP) Testing opens in new window
    Related National Coverage Documents
    N/A
    Public Version(s)
    Updated on 09/14/2019 with effective dates 10/01/2019 - N/A
    Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

    Expand/Collapse the Keywords section Keywords

    • B-type Natriuretic
    • BNP
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