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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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See the Turning Point site for specific requirements

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

Please submit your request to Turning Point

• http://www.myturningpoint-healthcare.com

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

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

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

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

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

• Clinical Coverage Policy No: 1R-4
• 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 submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

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

Please submit your request to Evolent

• https://www1.radmd.com/all-health-plans/trillium-health-resources

Resources

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