SUPERSEDED Local Coverage Determination (LCD)

Pulmonary Stress Testing

L33444

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33444
Original ICD-9 LCD ID
Not Applicable
LCD Title
Pulmonary Stress Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33444
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/15/2021
Revision Ending Date
12/06/2023
Retirement Date
N/A
Notice Period Start Date
12/22/2016
Notice Period End Date
02/05/2017

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the 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.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be 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 §1862(a)(1)(D) indicates no payment can be made for services that are research and/or experimental.

Title 42 CFR §410.32(a) indicates that diagnostic tests may be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements).

Title 42 CFR §410.32(d)(iii) describes who may furnish covered Medicare Part B diagnostic laboratory tests.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing, as well as undiagnosed conditions. The pulmonary stress test will be considered medically necessary for these conditions:

INDICATIONS:

Evaluation of exercise tolerance

• Determination of functional impairment or capacity
• Determination of exercise-limiting factors and pathophysiologic mechanisms

Evaluation of undiagnosed exercise intolerance

• Assessing contribution of cardiac and pulmonary etiology in coexisting disease
• Symptoms disproportionate to resting pulmonary and cardiac tests
• Unexplained dyspnea when initial cardiopulmonary testing is nondiagnostic

Evaluation of patients with cardiovascular disease

• Functional evaluation and prognosis in patients with heart failure
• Selection for cardiac transplantation
• Exercise prescription and monitoring response to exercise training for cardiac rehabilitation (special circumstances; i.e., pacemakers)

Evaluation of patients with respiratory disease

• Functional impairment assessment (see specific clinical applications)
• Chronic obstructive pulmonary disease:
     - Establishing exercise limitation(s) and assessing other potential contributing factors, especially occult heart disease (ischemia)
     - Determination of magnitude of hypoxemia and for O2 prescription
     - When objective determination of therapeutic intervention is necessary and not adequately addressed by standard pulmonary function testing
• Interstitial lung diseases:
     - Detection of early (occult) gas exchange abnormalities
     - Overall assessment/monitoring of pulmonary gas exchange
     - Determination of magnitude of hypoxemia and for O2 prescription
     - Determination of potential exercise-limiting factors
     - Documentation of therapeutic response to potentially toxic therapy
• Pulmonary vascular disease (careful risk–benefit analysis required)
• Cystic fibrosis
• Exercise-induced bronchospasm

Specific clinical applications include:

1) Preoperative evaluation for:

• Surgery involving lung resection
• Elderly patients undergoing major abdominal surgery
• Lung volume reduction surgery for emphysema

2) Clinical decision making:

• Exercise evaluation and prescription for pulmonary rehabilitation
• Evaluation for impairment–disability
• Evaluation for lung, heart–lung transplantation

LIMITATIONS:

Absolute and relative contraindications to exercise testing (field walking tests) include:

Absolute Contraindications

• Acute myocardial infarction (3-5 days)
• Unstable angina
• Uncontrolled arrhythmias causing symptoms or hemodynamic compromise
• Syncope
• Active endocarditis
• Acute myocarditis or pericarditis
• Symptomatic severe aortic stenosis
• Uncontrolled heart failure
• Acute pulmonary embolus or pulmonary infarction
• Thrombosis of lower extremities
• Suspected dissecting aneurysm
• Uncontrolled asthma
• Pulmonary edema
• SpO2 = 85% on room air
• Acute respiratory failure
• Acute non-cardiopulmonary disorder that may affect exercise performance or be aggravated by exercise (i.e., infection, renal failure, thyrotoxicosis)
• Mental impairment leading to inability to cooperate with the testing

Relative Contraindications

• Left main coronary artery stenosis or its equivalent
• Moderate stenotic valvular heart disease
• Severe untreated arterial hypertension at rest (200mmHg systolic, 120mmHg diastolic)
• Tachyarrythmias or bradyarrythmias
• High degree atrioventricular block
• Hypertrophic cardiomyopathy
• Significant pulmonary hypertension
• Advanced or complicated pregnancies
• Electrolyte abnormalities
• Orthopedic impairment that prevents walking

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

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

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Medical record documentation must indicate the medical necessity for performing the test. Documentation that the service and all its components were performed, including the results of the pulmonary stress test, should be available. This information is normally found in the office notes, progress notes, history and physical, and/or hard copy of the test results.

If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of test results and interpretations, along with copies of the ordering/referring physician's order for the studies. The physician must state the clinical indication/medical necessity for the study in this order for the test.

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

Sources of Information

N/A

Bibliography

Bauldoff G. AACVPR guidelines for pulmonary rehabilitation programs. 4th ed. Champaign, IL: Human Kinetics; 2011.

ATS/ACCP Statement on Cardiopulmonary Exercise Testing. Am J Respir Crit Care Med. 2003;167:211–277.

Holland AE, Spruit MA, Troosters T, et al. An official European respiratory society/American thoracic society technical standard: Field walking tests in chronic respiratory disease. Eur Respir J. 2014;44:1428-1446.

Salzman SH. The 6-min walk test: clinical and research role, technique, coding, and reimbursement. Chest. 2009;135(5):1345-1352.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
07/15/2021 R11

Under CMS National Coverage Policy updated descriptions for regulations Title 42 CFR §410.32(a) and §410.32(d)(iii). Under Bibliography changes were made to citations to reflect AMA citation guidelines and source for Medicare Learning Network was deleted as it is no longer accessible. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
10/24/2019 R10

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Pulmonary Stress Testing A56784 article. Formatting, punctuation and typographical errors were corrected throughout the LCD.

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.

 

  • Provider Education/Guidance
08/01/2019 R9

All coding located in the Coding Information section has been moved into the related Billing and Coding: Pulmonary Stress Testing A56784 article and removed from the LCD.

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.

  • Provider Education/Guidance
08/20/2018 R8

Under ICD-10 Codes that Support Medical Necessity Group 1: Codes added ICD-10 codes I27.0, I27.9, I27.21, I27.23 and I27.29. This revision is due to a reconsideration request.

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.

 

  • Reconsideration Request
02/26/2018 R7 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/01/2018 R6

Under CPT/HCPCS Codes Group 1: Codes deleted 94620, added 94617 and 94618, and the description was revised for 94621. Under ICD-10 Codes that Support Medical Necessity Group 1: Paragraph deleted the verbiage related to CPT/HCPCS codes. This revision is due to the Annual CPT/HCPCS Code Update.

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. 

 

 

 

  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R5

Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes I50.810, I50.811, I50.812, I50.813, I50.814, I50.82, I50.84 and I50.89. The code description was revised for M33.01 and M33.11. These revisions are due to the 2017 Annual ICD-10 Updates.

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. 

 

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
02/06/2017 R4 Under Coverage Indications, Limitations and/or Medical Necessity all of the existing verbiage was replaced with new verbiage. Under ICD-10 Codes that Support Medical Necessity added ICD-10 codes I42.0, I42.1, I42.2, I42.3, I42.4, I42.5, I42.6, I42.7, I42.8, I42.9, I50.22, I50.32, I50.42, Z48.21 and Z48.280. Under Sources of Information and Basis for Decision deleted Fishman A. Pulmonary Diseases and Disorders. 2nd ed. New York: McGraw-Hill Book Company;1988, Fischbach F. A Manual of Laboratory and Diagnostic Tests. 5th ed. Philadelphia, PA: Lippincott, Williams, & Wilkins;1996, Golish J, ed. Diagnostic Procedure Handbook. Hudson, Ohio: Lexi-Comp, Inc;1994 and Guenter CA, Welch MH, eds. Pulmonary Medicine. 2nd ed. Philadelphia, PA: Lippincott, Williams, & Wilkins Company;1982 and added Holland AE, Spruit MA, Troosters T, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J. 2014;44:1428-1446, Salzman SH. The 6-min walk test: clinical and research role, technique, coding, and reimbursement. Chest 2009;135(5):1345-1352, ATS/ACCP Statement on Cardiopulmonary Exercise Testing. Am J Respir Crit Care Med 2003;167:211–277, AACVPR. Guidelines for Pulmonary Rehabilitation Programs. 4th Edition. Champaign, IL: Human Kinetics;2011 and Medicare Learning Network. Available at: Home Oxygen Therapy. Accessed December 15, 2016.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
03/24/2016 R3 Under CMS National Coverage Policy revised the title for 42 CFR 410.32 and revised “3” to now read “iii”. The section number cited and the spelling of “Internet” were corrected for the following: CMS Internet-Only Manuals, Pub 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §240.7. Under Associated Information-Documentation Requirements the publisher name was corrected and the state of publication was added for Fischbach F. A Manual of Laboratory and Diagnostic Tests. 5th ed. The place of publication was added for the following: Golish J, ed. Diagnostic Procedure Handbook. Author initials and the publisher name were corrected and the state of publication was added for the following: Guenter C, Welch, M, eds. Pulmonary Medicine. 2nd ed.
  • Provider Education/Guidance
  • Typographical Error
01/04/2016 R2 Under ICD-10 Codes that Support Medical Necessity added ICD-10 code J44.1 to the ICD-10 code array. This revision was due to a Reconsideration Request.
  • Provider Education/Guidance
  • Reconsideration Request
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 Under CMS National Coverage Policy added “(NCD)” into title of Medicare National Coverage Determinations Manual.
  • Provider Education/Guidance
  • Other (Maintenance
    Annual Review)
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/27/2023 12/07/2023 - N/A Currently in Effect View
07/09/2021 07/15/2021 - 12/06/2023 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Pulmonary Stress Testing

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