Local Coverage Article Billing and Coding

Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP)

A58218

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Contractor Information

Article Information

General Information

Article ID
A58218
Article Title
Billing and Coding: Computed Tomography Cerebral Perfusion Analysis (CTP)
Article Type
Billing and Coding
Original Effective Date
11/02/2020
Revision Effective Date
12/12/2021
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 2022 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 © 2022 American Dental Association. All rights reserved.

Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced 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. 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.

CMS National Coverage Policy

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Article Guidance

Article Text

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.)
• Performance of the study in a stoke center

Effective 12/12/2021 please append computed tomography cerebral perfusion analysis identified with CPT 0042T with the KX modifier to attest the CTP analysis was performed in a certified stroke center.

If the service is provided in the emergency room (POS 23) the ER must be part of the certified stroke center to qualify for coverage.

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.

Each claim must be submitted with ICD-10-CM codes that reflect the condition of the patient and indicate the reason(s) for which the service was performed. Claims submitted without ICD-10-CM codes will
be returned.

The documentation of the study requires a formal written report, with clear identifying demographics, the name of the interpreting provider, the reason for the tests, an interpretive report and copies of images. The computerized image reconstruction data should also be maintained.

Documentation must be available to Medicare upon request.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
0042T CEREBRAL PERFUSION ANALYSIS USING COMPUTED TOMOGRAPHY WITH CONTRAST ADMINISTRATION, INCLUDING POST-PROCESSING OF PARAMETRIC MAPS WITH DETERMINATION OF CEREBRAL BLOOD FLOW, CEREBRAL BLOOD VOLUME, AND MEAN TRANSIT TIME

CPT/HCPCS Modifiers

Group 1

(1 Code)
Group 1 Paragraph

N/A

Group 1 Codes
CodeDescription
KX REQUIREMENTS SPECIFIED IN THE MEDICAL POLICY HAVE BEEN MET

ICD-10-CM Codes that Support Medical Necessity

Group 1

(10 Codes)
Group 1 Paragraph

The ICD-10-CM diagnosis codes in Group 1 support the medical necessity of CPT code 0042T in the CPT/HCPCS Code section-Group1 above.

Group 1 Codes
CodeDescription
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery
I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle 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

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.

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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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
12/12/2021 R1

Revision Effective 12/12/2021

Revision Explanation: Added information on use of the KX modifier and that the ER must be part of the certified stroke center.

 

 

Revision Effective: 06/17/2021
Revision Explanation: Annual review, no changes were made.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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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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Public Versions
Updated On Effective Dates Status
10/18/2021 12/12/2021 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

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