Local Coverage Determination (LCD)

Percutaneous Coronary Intervention


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Document Information

LCD Title
Percutaneous Coronary Intervention
Proposed LCD in Comment Period
Source Proposed LCD
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 11/07/2019
Revision Ending Date
Retirement Date
Notice Period Start Date
Notice Period End Date
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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CMS National Coverage Policy

Language quoted from 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 an NCD. See Section 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):

Section 1862 (a)(1)(A), this section allows coverage and payment for only those services considered medically reasonable and necessary.

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

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Since Gruentzig’s 1979 report of coronary balloon angioplasty, percutaneous transluminal coronary interventions have substantively altered the management of patients with symptomatic arteriosclerotic heart disease. Balloon angioplasty rapidly expanded from single to multiple vessels and from simple to complex anatomic substrates. Transluminal interventions now encompass balloon dilation (PTCA), a variety of atherectomy devices, high pressure and biologic/polymer coated stents as well as transluminal thrombectomy. Additionally, intracoronary ultrasound is often employed to assess the efficacy of these interventions. In addition to medical therapy and coronary bypass surgery, percutaneous coronary intervention has emerged as a primary option for the management of patients with acute coronary syndromes and selected patients with chronic angina.


Percutaneous coronary intervention (PCI) may be indicated in the management of :

  • patients with acute coronary syndrome (eg acute myocardial infarction, unstable angina)
  • patients with a history of significant obstructive atherosclerotic disease
  • patients with restenosis of a coronary artery previously treated with intracoronary stent or other revascularization procedure
  • patients with chronic angina
  • patients with silent ischemia

Intracoronary ultrasound may be separately covered when needed to assess the extent of coronary stenosis if equivocal on angiography, or when needed to assess the patency and integrity of a coronary artery post-intervention. Alternatively, intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement may be performed to assess the degree of stenosis within a vessel.


A diagnostic cardiac catheterization to assess the nature of the lesion(s) prior to the intervention is a covered service. The diagnostic cardiac catheterization may be performed at any time prior to the PCI, including the same day as the PCI.

Performance of a diagnostic cardiac catheterization and interventional procedure on the same day is increasingly the standard of practice. While there may be reasons for delaying the interventional procedure (e.g., transfer from a community hospital to a tertiary center, excessive dye load, further treatment planning or evaluation of angiography, etc.), it is recommended that both procedures be performed during the same encounter when medically appropriate. Separation of these procedures for the purpose of circumventing the multiple surgery pricing, or for the convenience of physician or hospital scheduling, is considered an inappropriate practice and may subject the services to review and denial for medical necessity. The decision to stage these procedures is deferred to the judgment of the interventional cardiologist, and individualized only to the clinical needs of the patient. (e.g., dye load already received, need to correlate findings with other test results, etc). Reasons for delaying indicated intervention should be documented in the medical record. Unless there is a new clinical event or change in symptomatology, examination or other test results, a repeat diagnostic catheterization service within three months of a previous diagnostic catheterization, and prior to completion of the staged intervention is generally not reimbursable and is considered not to be reasonable and necessary.

Angiography during the procedure, used to monitor the course of the intervention, is considered part of the PCI and is not separately billable to Medicare. Diagnostic angiography may be separately payable in situations where no previous catheter-based coronary angiography study is available, or a previous study is no longer adequate due to changes in the patient’s condition.

The deployment of a device for distal embolic protection during an interventional procedure is considered part of the more complex procedure and is not separately billable.

Prophylactic insertion of a temporary transvenous pacemaker, repositioning or replacement of catheters and administration of medications during the procedure are included in the procedure and are not separately billable. Right heart catheterization and insertion of a Swan-Ganz catheter are not generally medically necessary for a PCI and will be denied, unless medically necessary when performed incident to a diagnostic catheterization prior to the intervention. Standby services of a surgeon or anesthesiologist are not covered services.

Intracoronary injections of drugs during diagnostic or therapeutic procedures are considered to be part of the procedure and are not separately reimbursable.

Percutaneous vascular closure devices (PVCD) may be used to facilitate closure of an arterial puncture site after angiography, cardiac catheterization and interventional cardiology procedures in addition to or in place of manual compression, use of a mechanical clamp or a sandbag, or a combination of these methods. These services are inherent to the invasive procedure and are not separately payable.

Summary of Evidence


Analysis of Evidence (Rationale for Determination)


General Information

Associated Information
Sources of Information

CMD Cardiology Work Group.


AMA CPT 2013, Professional Edition. 500-502.

Anson BJ. Morris’ Human Anatomy, 12th ed. McGraw Hill, Inc. New York. 1966:650.

Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed. Philadelphia, PA: W.B. Saunders Company. 2008.

CardioSource. A Guide to the 2013 Coding Changes for Cardiology. http://www.cardiosource.org/Advocacy/Physician-Payment/Coding-Changes-for-2013.aspx. American College of Cardiology. 2012.

Gardner E, Gray DJ, O’Rahilly RO. Anatomy, WB Saunders. Philadelphia. 1960:405-408.

James TN. Anatomy of the Coronary Arteries, Paul B. Hoebler, Inc. New York. 1961.

Levin DC, Gardiner Jr GA. Heart Disease: A Textbook of Cardiovascular Medicine, 4th ed. WB Saunders. Philadelphia. 1992:239-245.

Smith S, Dove J, Jacobs A, et al. ACC/AHA guidelines for percutaneous intervention (Revision of the 1993 PTCA Guidelines). Journal of the American College of Cardiology. 2001;37(8):2239i-2239lxvi.

Topol E. Textbook of Interventional Cardiology, 4th ed. Cleveland, Ohio: Saunders. 2003.

Urchel Jr HC, Razzuk MA. Cardiac Surgery. 2nd ed. (Ed. Norman JC), Appelto Century Crofts. New York. 1972:447-472.

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
11/07/2019 R10

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A56823. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
01/01/2019 R9

HCPCS code descriptor updates for 2019

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2018 R8

HCPCS code descriptor updates for 2018

  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R7

LCD revised for annual ICD-10 updates for 2018.

ICD-10 codes I21.9, I21.A1 and I21.A9 were added as payable for CPT codes 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975, and C9600 - C9608.

DATE (10/01/2017): At this time, the 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.

  • Revisions Due To ICD-10-CM Code Changes
01/01/2017 R6 Correct revision effective date to 01/01/2017.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R5 CPT descriptor changes due to 2017 updates
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R4 LCD revised for annual ICD-10 updates. The following ICD-10 codes were added:
  • Revisions Due To ICD-10-CM Code Changes
01/01/2016 R3 LCD updated with revised descriptors for HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9607, and C9608.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 ICD-10 codes were revised to add the 7th digit for D=subsequent encounter and S=sequela, where the 7th digit, A=initial encounter was already included.
  • Provider Education/Guidance
10/01/2015 R1 LCD updated with changes made subsequent to first posting.
  • Other

Associated Documents

Related National Coverage Documents
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