PA Lookup

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.

CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.

For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.

One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.

For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Authorization Guidelines

Please include any records and any other information that you believe support the member has met the applicable medical necessity criteria.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.

CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.

For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.

One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.

For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Allowed twice in a 280-day period.

Claims for testing beyond this limit are subject to medical necessity review.

The limitation is not intended to prevent medically necessary repetition, but to prevent medically unnecessary duplication.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

Additional Service Specifics

Fetal echocardiography is not covered when used for routine screening for congenital heart disease in the absence of the policy's listed risk factors; when the pregnancy is low risk and ultrasound examination shows normal anatomic findings; when premature contractions are only occasional and there is no sustained tachycardia or signs of dysfunction or distress; or when a non-cardiovascular abnormality is present but evaluating the cardiovascular system would not change obstetrical decision making or fetal outcome.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Allowed twice in a 280-day period.

Claims for testing beyond this limit are subject to medical necessity review.

The limitation is not intended to prevent medically necessary repetition, but to prevent medically unnecessary duplication.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

Additional Service Specifics

Fetal echocardiography is not covered when used for routine screening for congenital heart disease in the absence of the policy's listed risk factors; when the pregnancy is low risk and ultrasound examination shows normal anatomic findings; when premature contractions are only occasional and there is no sustained tachycardia or signs of dysfunction or distress; or when a non-cardiovascular abnormality is present but evaluating the cardiovascular system would not change obstetrical decision making or fetal outcome.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Allowed twice in a 280-day period.

Claims for testing beyond this limit are subject to medical necessity review.

The limitation is not intended to prevent medically necessary repetition, but to prevent medically unnecessary duplication.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

Additional Service Specifics

Fetal echocardiography is not covered when used for routine screening for congenital heart disease in the absence of the policy's listed risk factors; when the pregnancy is low risk and ultrasound examination shows normal anatomic findings; when premature contractions are only occasional and there is no sustained tachycardia or signs of dysfunction or distress; or when a non-cardiovascular abnormality is present but evaluating the cardiovascular system would not change obstetrical decision making or fetal outcome.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Conditional Requirements

Prior authorization is required if provider is not part of the  Pregnancy Medical Home program, except if done in emergency department or inpatient.

Limits

Allowed twice in a 280-day period.

Claims for testing beyond this limit are subject to medical necessity review.

The limitation is not intended to prevent medically necessary repetition, but to prevent medically unnecessary duplication.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

Additional Service Specifics

Fetal echocardiography is not covered when used for routine screening for congenital heart disease in the absence of the policy's listed risk factors; when the pregnancy is low risk and ultrasound examination shows normal anatomic findings; when premature contractions are only occasional and there is no sustained tachycardia or signs of dysfunction or distress; or when a non-cardiovascular abnormality is present but evaluating the cardiovascular system would not change obstetrical decision making or fetal outcome.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Electrocardiography is a procedure for recording electrical changes in the heart. The electrocardiogram (ECG or EKG) shows the series of waves that relate to the electrical impulses that occur during each beat of the heart. EKGs can evaluate and detect cardiac problems. Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart. Ultrasound waves rebound or echo off the heart to show the size, shape, and movement of the heart's valves and chambers. Each component is crucial to permit a full assessment of the heart and an accurate diagnosis of certain cardiovascular diseases.

Limits

Electrocardiogram A maximum of four, 12-lead EKGs is allowed per day.

Microvolt T-Wave Alternans Microvolt T-wave alternans is limited to once per day, regardless of whether it is performed while the beneficiary is at rest, during stress, or in a combination thereof.

The equipment used must be FDA approved for this indication and able to detect as little as 1 microvolt of T-wave alternans.

Holter Monitor The Holter monitor test is limited to one per 24-hour period.

Cardiac (Ambulatory) Event Monitors

• a. Event monitoring is limited to once per 30 days, regardless of the number of

transmissions.

• b. In order to bill any of the services that include 24-hour attended monitoring,

the provider must be available during the entire 24-hour period.

• c. The provider of the service must be capable of receiving and recording

transmissions, including receipt of the EKG signal as well as voice transmission relaying any associated symptoms.

• d. The person receiving the transmission must be a technician, nurse, or

physician trained in interpreting EKGs and clinical responses to abnormal EKGs.

• e. The transmission is reviewed for significant symptoms or EKG

abnormalities.

• f. Technicians should have immediate 24-hour access to a physician to review

transmitted data and make clinical decisions regarding the beneficiary.

• g. The provider must be capable of immediately notifying the beneficiary with

emergency instructions from the supervising or the attending physician, when appropriate.

• h. The emergency instructions for the beneficiary, as well as when and how to

contact available facilities to assist the beneficiary in case of emergencies, should be included by the attending physician in the referral for the monitoring Transthoracic Echocardiography TTE is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the beneficiary is transferred to a tertiary hospital for further specialized evaluation, the beneficiary has a change in clinical status, or guidance is needed during an interventional procedure.

Transesophageal Echocardiography TEE is limited to one per day for screening purposes.

Two intraoperative TEEs are allowed per day when performed during cardiac surgery as long as performed as part of the operative procedure. The preoperative (or pre-bypass) and post-operative (or post-bypass) components must be documented. Only the first intraoperative TEE can include the code for probe placement.

Doppler Echocardiography Doppler echocardiography procedures are add-on codes and must be listed separately in addition to the primary procedure. They are not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Intracardiac Echocardiography Intracardiac echocardiography is limited to one procedure per day for guidance of a catheter-based intervention. Intracardiac echocardiography is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

Fetal Echocardiography Fetal Echocardiography is limited to one per day. A repeat test is allowed only when medically necessary and the code is amended with modifier 76 or 77. A repeat test might be medically necessary if, for example, the pregnant mother (fetus is the beneficiary) is transferred to a tertiary hospital for further specialized evaluation, the fetus has a change in clinical status, or guidance is needed during an interventional procedure.

Coronary Intravascular Ultrasound Coronary IVUS includes all transducer manipulations and repositioning within the specific vessel being examined, both before and after therapeutic intervention.

IVUS is an add-on code and must be listed separately in addition to the primary procedure. It is not to be reported as a stand-alone code and must be reported by the same physician. The primary codes are identified in the CPT Manual for each add-on code.

One IVUS, initial vessel, is allowed per day. Three additional vessels are allowed per day, with the initial vessel IVUS.

Diagnosis Requirements

Specific covered indications for cardiovascular stress testing are: screening for coronary atherosclerosis and myocardial ischemia; follow-up after myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft to assess functional improvement during cardiac rehabilitation; follow-up of beneficiaries with palliated or unpalliated congenital heart disease; follow-up of pediatric and adult beneficiaries with dilated cardiomyopathy regardless of etiology; follow-up of pediatric and adult beneficiaries with hypertrophic cardiomyopathy; pre-operative assessment of beneficiaries being considered for valve replacement; and follow-up after valve replacement.

Place of Service

Inpatient, Outpatient, Office, Home, Intermediate care facility, Skilled nursing facility, and Independent Diagnostic Testing Facility

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1R-4
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Authorization Guidelines

The provider(s) shall submit the following:

• a. the prior approval request; and
• b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy.

• c. If the Medicaid recipient is under 21 years of age, information supporting

that all EPSDT criteria are met and evidence-based literature supporting the request, if available.

Limits

Chorionic villus sampling is performed during pregnancy at 10 to 12 weeks.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.

Limits

Generally performed at or beyond 14 weeks gestation for genetic testing.

Other procedures performed on the same date of service as amniocentesis are covered if performed by the same provider and billed according to modifier rules.

Other related procedures during the amniocentesis follow-up period, and unrelated procedures during that follow-up period, are covered if performed by the provider who performed the amniocentesis. Amniocentesis is not covered when performed for sex determination without documented risk of an X-linked disorder, or for routine screening without the risk factors listed in the amniocentesis coverage subsection.

Exclusions

Ultrasound is not covered when:

-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:

-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:

-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP

Age Group Details

Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria

Place of Service

Inpatient, Outpatient, Physician’s Office.

How to Submit

N/A - No authorization is required

Resources

• 1E-4 Fetal Surveillance
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

• https://carepro.evolent.com/