LCD L33756

Coverage Guidance

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Transesophageal Echocardiogram. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Transesophageal Echocardiogram and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual,

• Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,

• Chapter 1, Part 4, Section 220.5 Ultrasound Diagnostic Procedures (Effective May 22, 2007)

• CMS IOM Publication 100-04, Medicare Claims Processing Manual,

• Chapter 4, Section 20 Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)

• CMS IOM Publication 100-08, Medicare Program Integrity Manual,

• Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

National Correct Coding Initiative (NCCI) Citation:

• NCCI Policy Manual for Medicare Services,

• Chapter 11, Section I. Cardiovascular Services, Subsections 15., 21., 24., and 32.

• Chapter 11, Section U. Evaluation and Management (E&M) Services, Subsection 9.

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References:

• Code of Federal Regulations (CFR), Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions and Part 410.33 Independent diagnostic testing facility.

Indications and Limitations of Coverage

History/Background and/or General Information

Transesophageal Echocardiography (TEE) is a cardiac diagnostic procedure in which a modified endoscope, with an ultrasound transducer, is passed into the esophagus and/or stomach in order to obtain 2-D/3D echo images and spectral and color Doppler information about the heart and its great vessels.

Transesophageal Echocardiography (TEE) imaging is a viable alternative when transthoracic imaging is problematic or difficult. In many instances, abnormalities can be displayed that are missed with standard diagnostic techniques, and the images displayed are often of superior quality because of the high-resolution probes that can be used.

Covered Indications

Transesophageal echocardiogram will be considered medically necessary in any of the following circumstances:

• Examination of prosthetic heart valves, primarily mitral

• Arrhythmias – assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for which the results of the test will influence treatment decisions. TEE may complement transthoracic echocardiography particularly to assess for left atrial thrombus.

• Detection of:

• aortic dissection

• atrial septal defect

• congenital heart disease

• embolism or thrombosis, primarily involving left atrium

• intracardiac foreign bodies, tumors or masses

• mitral valve regurgitation

• vegetative endocarditis

• Intra-operative guide to left ventricular function

• Inadequacy of transthoracic echo due to:

• chest wall deformity, COPD

• open heart or chest surgery

• chest trauma

• obesity

Limitations

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

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Analysis of Evidence

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Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: Transesophageal Echocardiogram (A57179) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: Transesophageal Echocardiogram (A57179) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Bibliography

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