CMS Pub. 100-04, ch. 32, § 370.1

Effective for claims with dates of service on and after March 21, 2006, MACs shall accept CPT

93025 (MTWA for assessment of ventricular arrhythmias) for MTWA diagnostic testing for the

evaluation of patients at risk for SCD with the SA method of analysis only. All other methods of

analysis for MTWA are non-covered.

Effective for claims with dates of service on and after January 13, 2015, MACs shall at their

discretion determine coverage for CPT 93025 for MTWA diagnostic testing for the evaluation of

patients at risk for SCD with methods of analysis other than SA. The –KX modifier shall be used as

an attestation by the practitioner and/or provider of the service that documentation is on file verifying

the MTWA was performed using a method of analysis other than SA for the evaluation of patients at

risk for SCD from ventricular arrhythmias and that all other NCD criteria was met.

NOTE: The –KX modifier is NOT required on MTWA claims for the evaluation of patients at

risk for SCD if the SA analysis method is used.

NOTE: This diagnosis code list/translation was approved by CMS/Coverage. It may or may not be a

complete list of covered indications/diagnosis codes that are covered but should serve as a finite

starting point.

As this policy indicates, individual A/B MACs within their respective jurisdictions have the discretion

to make coverage determinations they deem reasonable and necessary under section 1862(a)(1)(A) of

the Social Security Act. Therefore, A/B MACs may have additional covered diagnosis codes in their

individual policies where contractor discretion is appropriate.

ICD-10-Codes:

ICD-10 CM ICD-10 DX Description

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

I21.A1 Myocardial infarction type 2

I21.B Myocardial infarction with coronary microvascular dysfunction

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

I24.81 Acute coronary microvascular dysfunction

I24.89 Other forms of acute ischemic heart disease

I24.9 Acute ischemic heart disease, unspecified

I47.0 Re-entry ventricular arrhythmia

I47.2 Ventricular tachycardia

I49.01 Ventricular fibrillation

I49.02 Ventricular flutter

R55 Syncope and collapse