DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)

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Draft Article
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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Draft Article ID
DA59721
Original ICD-9 Article ID
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Draft Article Title
Billing and Coding: Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)
Article Type
Billing and Coding
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CMS National Coverage Policy

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

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §20 Payment Conditions for Radiology Services

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, §20.9 National Correct Coding Initiative (NCCI)

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA) DL39851.

CCTA Requirements

The patient shall have a medically indicated CCTA and meet all requirements per the LCD, Cardiac Computed Tomography & Angiography (CCTA) L33423. AI-QCT/AI-CPA shall not be performed until after the base study (CCTA) has been completed and interpreted.

As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for AI-QCT/AI-CPA review must be reported on the claim.

General Guidelines for Claims submitted to Part A or Part B Medicare Administrative Contractors (MACs):

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.

Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines

An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.

Effective from April 1, 2010, non-covered services should be billed with modifier -GA, -GX, -GY, or -GZ, as appropriate.

The GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that ‎he/she accepts responsibility for payment.‎ The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

The GX modifier (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.

The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.

If the service is statutorily non-covered, or without a benefit category, submit the ‎appropriate CPT/HCPCS code with the GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.

Guidelines for Documentation and Utilization:

Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD (Please see " Coverage Guidance, Limitations, and Reasonable and Necessary Criteria").

The patient’s medical record should document ALL of the following:

  • History and physical exam with detail(s) sufficient to assess pre-test probability for CAD;
  • Description of symptoms consistent with stable ischemic heart disease;
  • The clinical findings that led to the initial performance of the CCTA, and the CCTA must be completed and interpreted before the performance of AI-QCT/AI-CPA;
  • The clinical indication for the addition of AI-QCT/AI-CPA must be documented;
  • Coronary Computed Tomographic Angiography report; and
  • AI-QCT/AI-CPA analysis report.

Response To Comments

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Coding Information

Bill Type Codes

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Revenue Codes

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CPT/HCPCS Codes

Group 1

(4 Codes)
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Group 1 Codes
Code Description
0623T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; DATA PREPARATION AND TRANSMISSION, COMPUTERIZED ANALYSIS OF DATA, WITH REVIEW OF COMPUTERIZED ANALYSIS OUTPUT TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT
0624T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; DATA PREPARATION AND TRANSMISSION
0625T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; COMPUTERIZED ANALYSIS OF DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY
0626T AUTOMATED QUANTIFICATION AND CHARACTERIZATION OF CORONARY ATHEROSCLEROTIC PLAQUE TO ASSESS SEVERITY OF CORONARY DISEASE, USING DATA FROM CORONARY COMPUTED TOMOGRAPHIC ANGIOGRAPHY; REVIEW OF COMPUTERIZED ANALYSIS OUTPUT TO RECONCILE DISCORDANT DATA, INTERPRETATION AND REPORT
N/A

CPT/HCPCS Modifiers

Group 1

(4 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
GA WAIVER OF LIABILITY STATEMENT ISSUED AS REQUIRED BY PAYER POLICY, INDIVIDUAL CASE
GX NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY
GY ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT
GZ ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE AND NECESSARY
N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(1 Code)
Group 1 Paragraph

Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy has been met.

Group 1 Codes
Code Description
R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulation
N/A

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

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ICD-10-PCS Codes

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Additional ICD-10 Information

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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
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.

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Other Coding Information

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Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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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Public Versions
Updated On Archived Date Status
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Keywords

  • Artificial Intelligence Enabled CT Based Quantitative Coronary Topography
  • AI-QCT
  • AI-CPA
  • Coronary Plaque Analysis