SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: B-type Natriuretic Peptide (BNP) Testing

A56425

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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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General Information

Source Article ID
N/A
Article ID
A56425
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: B-type Natriuretic Peptide (BNP) Testing
Article Type
Billing and Coding
Original Effective Date
10/01/2015
Revision Effective Date
12/01/2022
Revision Ending Date
11/15/2023
Retirement Date
N/A
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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

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9: 100 General Billing Requirements

CMS Publication.100-04, Medicare Claims Processing Manual, Transmittal No. 820, Change Request #4210, dated 2/1/2006, changes the revenue codes both RHCs and FQHCs use when billing for RHC/FQHC services.

Article Guidance

Article Text

This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy L33943 B-type Natriuretic Peptide (BNP) Testing.

As a diagnostic test, BNP testing is not expected to be performed more than four times in a given year. See the “Indications and Limitations of Coverage” section (above) for frequency parameters for BNP testing to monitor the effectiveness of nesiritide therapy.


The use of BNP for monitoring CHF is not covered.

General Guidelines for Claims submitted to Part A or Part B MAC:

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. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. 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 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.

 

Modifier GX (“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, will automatically be denied 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.

Documentation Requirements

The patient’s medical record should include but is not limited to:

  • The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,
  • Relevant medical history
  • Results of pertinent tests/procedures
  • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)

 

 Other Comments:

For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS to process their claims.

Bill type codes only apply to providers who bill these services to the Part A MAC Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

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
014x Hospital - Laboratory Services Provided to Non-patients
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
030X Laboratory - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0522 Freestanding Clinic - Home Visit by RHC/FQHC Practitioner
0524 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a Covered Part A Stay
0525 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility
0527 Freestanding Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area
0528 Freestanding Clinic - Visit by RHC/FQHC Practitioner to Other non-RHC/FQHC site (e.g. Scene of Accident)
096X Professional Fees - General Classification
0971 Professional Fees - Laboratory
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0974 Professional Fees - Radiology - Nuclear
0975 Professional Fees - Operating Room
0976 Professional Fees - Respiratory Therapy
0977 Professional Fees - Physical Therapy
0978 Professional Fees - Occupational Therapy
0979 Professional Fees - Speech Pathology
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
0984 Professional Fees - Medical Social Services
0985 Professional Fees - EKG
0986 Professional Fees - EEG
0987 Professional Fees - Hospital Visit
0988 Professional Fees - Consultation
0989 Professional Fees - Private Duty Nurse
N/A

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
83880 NATRIURETIC PEPTIDE
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

(55 Codes)
Group 1 Paragraph

It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.

 

Group 1 Codes
Code Description
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I20.0 Unstable angina
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
I21.3 ST elevation (STEMI) myocardial infarction of unspecified site
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.112 Atherosclerosic heart disease of native coronary artery with refractory angina pectoris
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.712 Atherosclerosis of autologous vein coronary artery bypass graft(s) with refractory angina pectoris
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.722 Atherosclerosis of autologous artery coronary artery bypass graft(s) with refractory angina pectoris
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
I25.732 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with refractory angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.752 Atherosclerosis of native coronary artery of transplanted heart with refractory angina pectoris
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
I25.762 Atherosclerosis of bypass graft of coronary artery of transplanted heart with refractory angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.792 Atherosclerosis of other coronary artery bypass graft(s) with refractory angina pectoris
I31.1 Chronic constrictive pericarditis
I42.0 Dilated cardiomyopathy
I42.5 Other restrictive cardiomyopathy
I42.8 Other cardiomyopathies
I42.9 Cardiomyopathy, unspecified
I50.1 Left ventricular failure, unspecified
I50.20 - I50.23 Unspecified systolic (congestive) heart failure - Acute on chronic systolic (congestive) heart failure
I50.30 - I50.33 Unspecified diastolic (congestive) heart failure - Acute on chronic diastolic (congestive) heart failure
I50.40 - I50.43 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure - Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.9 Heart failure, unspecified
R06.00 Dyspnea, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.2 Wheezing
R06.82 Tachypnea, not elsewhere classified
R06.9 Unspecified abnormalities of breathing

Group 2

(22 Codes)
Group 2 Paragraph

The following ICD-10-CM codes support medical necessity in non hospital setting.

Group 2 Codes
Code Description
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
I50.1 Left ventricular failure, unspecified
I50.20 - I50.23 Unspecified systolic (congestive) heart failure - Acute on chronic systolic (congestive) heart failure
I50.30 - I50.33 Unspecified diastolic (congestive) heart failure - Acute on chronic diastolic (congestive) heart failure
I50.40 - I50.43 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure - Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure
I50.9 Heart failure, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.2 Wheezing
R06.82 Tachypnea, not elsewhere classified
R06.9 Unspecified abnormalities of breathing
N/A

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

Group 1

Group 1 Paragraph

N/A

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
014x Hospital - Laboratory Services Provided to Non-patients
021x Skilled Nursing - Inpatient (Including Medicare Part A)
022x Skilled Nursing - Inpatient (Medicare Part B only)
023x Skilled Nursing - Outpatient
071x Clinic - Rural Health
072x Clinic - Hospital Based or Independent Renal Dialysis Center
073x Clinic - Freestanding
077x Clinic - Federally Qualified Health Center (FQHC)
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.

Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.

Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.

 

 


Code Description
030X Laboratory - General Classification
0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC
0522 Freestanding Clinic - Home Visit by RHC/FQHC Practitioner
0524 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a Covered Part A Stay
0525 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility
0527 Freestanding Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area
0528 Freestanding Clinic - Visit by RHC/FQHC Practitioner to Other non-RHC/FQHC site (e.g. Scene of Accident)
096X Professional Fees - General Classification
0971 Professional Fees - Laboratory
0972 Professional Fees - Radiology - Diagnostic
0973 Professional Fees - Radiology - Therapeutic
0974 Professional Fees - Radiology - Nuclear
0975 Professional Fees - Operating Room
0976 Professional Fees - Respiratory Therapy
0977 Professional Fees - Physical Therapy
0978 Professional Fees - Occupational Therapy
0979 Professional Fees - Speech Pathology
0981 Professional Fees - Emergency Room Services
0982 Professional Fees - Outpatient Services
0983 Professional Fees - Clinic
0984 Professional Fees - Medical Social Services
0985 Professional Fees - EKG
0986 Professional Fees - EEG
0987 Professional Fees - Hospital Visit
0988 Professional Fees - Consultation
0989 Professional Fees - Private Duty Nurse
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
12/01/2022 R7

R6

Revision Effective: 12/01/2022

Revision Explanation: Annual review, no changes 

10/01/2022 R6

R5

Revision Effective: 10/01/2022

Revision Explanation: In revision 4 ICD-10 code I25.702 was listed as being added to group 1 in error. 

10/01/2022 R5

R4

Revision Effective: 10/01/2022

Revision Explanation: Annual ICD-10 Update, added the following codes: I25.112, I25.702, I25.712, I25.722, I25.732, I25.752, I25.762, I25.792.

11/25/2021 R4

R3

Revision Effective: 11/25/2021

Revision Explanation: Annual Review, the Time Based Code information no long applies to the article and was removed from the article.

11/28/2019 R3

R3

Revision Effective: N/A

Revision Explanation: Annual Review, no changes were made.

11/28/2019 R2

R2

Revision Effective: 11/28/2019

Revision Explanation: Add regulation to the CMS National Policy section and add other comments section in article text. Also added information concerning how many times the test can be billed and what should not be used for testing.

09/19/2019 R1

R1

Revision Effective: 09/19/2019

Revision Explanation: Converted article into new Billing and Coding template no other changes made.

 

 


 

N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L33943 - B-type Natriuretic Peptide (BNP) Testing
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
11/29/2023 12/07/2023 - N/A Currently in Effect View
11/07/2023 11/16/2023 - 12/06/2023 Superseded View
11/23/2022 12/01/2022 - 11/15/2023 Superseded You are here
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