Local Coverage Determination (LCD)

Pulmonary Stress Testing

L33444

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B MAC	10112 - MAC B	J - J	Alabama
Palmetto GBA	A and B MAC	10212 - MAC B	J - J	Georgia
Palmetto GBA	A and B MAC	10312 - MAC B	J - J	Tennessee
Palmetto GBA	A and B and HHH MAC	11202 - MAC B	J - M	South Carolina
Palmetto GBA	A and B and HHH MAC	11302 - MAC B	J - M	Virginia
Palmetto GBA	A and B and HHH MAC	11402 - MAC B	J - M	West Virginia
Palmetto GBA	A and B and HHH MAC	11502 - MAC B	J - M	North Carolina

LCD Information

Document Information

LCD ID
L33444

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 12/07/2023

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
12/22/2016

Notice Period End Date
02/05/2017

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

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.

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §231 Pulmonary Rehabilitation (PR) Program Services Furnished On or After January 1, 2010

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §240.7 Postural Drainage Procedures and Pulmonary Exercises

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

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Contact for Comments on Proposed LCD

Coding Information

ICD-10-CM Codes that Support Medical Necessity

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

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
12/07/2023	R12	Under *CMS National Coverage Policy* added the following regulations from the related billing and coding article: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §231 Pulmonary Rehabilitation (PR) Program Services Furnished On or After January 1, 2010 and CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §240.7 Postural Drainage Procedures and Pulmonary Exercises.	Provider Education/Guidance
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 21^stCentury 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 21^stCentury 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)

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A55409 - (MCD Archive Site)
A56784 - Billing and Coding: Pulmonary Stress Testing
LCDs
DL33444 - (MCD Archive Site)

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

Keywords

Pulmonary Stress Testing

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Pulmonary Stress Testing

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

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

Group 1

Additional ICD-10 Information

General Information

Revision History Information

Associated Documents

Keywords

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