LCD Reference Article Billing and Coding Article

Billing and Coding: Transesophageal Echocardiography (TEE)

A56505

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Source Article ID
N/A
Article ID
A56505
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Transesophageal Echocardiography (TEE)
Article Type
Billing and Coding
Original Effective Date
04/25/2019
Revision Effective Date
10/01/2024
Revision Ending Date
N/A
Retirement Date
N/A

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  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text


This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35016, Transesophageal Echocardiography (TEE). Please refer to the LCD for reasonable and necessary requirements. 

Coding Guidance

Notice
: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

CPT code 93355 is used to report TEE services during transcatheter intracardiac therapies. CPT code 93355 is reported once per intervention and only by an individual who is not performing the interventional procedure. CPT code 93355 includes the work of passing the endoscopic ultrasound transducer through the mouth into the esophagus, when performed by the individual performing the TEE, diagnostic transesophageal echocardiography and ongoing manipulation of the transducer to guide sizing and/or placement of implants, determination of adequacy of the intervention, and assessment for potential complications. Real-time image acquisition, measurements, and interpretation of image(s), documentation of completion of the intervention, and final written report are included in this code.

CPT code 93312 (HCPCS code C8925 for Outpatient Prospective Payment System [OPPS]) should be billed when contrast is used or CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) for the complete procedure, including probe placement, image acquisition, interpretation and report. CPT code 93315 (HCPCS code C8926 for OPPS billing when contrast is used) should be used for congenital anomalies only.

Hospitals should use guidelines and descriptors associated with the applicable Level 1 CPT code(s) to bill for echocardiograms without contrast.

All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.

Documentation Requirements

    1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
    2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
    3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(501 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT/HCPCS codes: 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, 93355, C8925, C8926, C8927, Q9955, Q9956, and Q9957.

Group 1 Codes
Code Description
A18.84 Tuberculosis of heart
A40.0 Sepsis due to streptococcus, group A
A40.1 Sepsis due to streptococcus, group B
A40.3 Sepsis due to Streptococcus pneumoniae
A40.8 Other streptococcal sepsis
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
A41.1 Sepsis due to other specified staphylococcus
A41.3 Sepsis due to Hemophilus influenzae
A41.4 Sepsis due to anaerobes
A41.51 Sepsis due to Escherichia coli [E. coli]
A41.52 Sepsis due to Pseudomonas
A41.53 Sepsis due to Serratia
A41.59 Other Gram-negative sepsis
A41.81 Sepsis due to Enterococcus
A41.89 Other specified sepsis
B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere
B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere
B95.7 Other staphylococcus as the cause of diseases classified elsewhere
B95.8 Unspecified staphylococcus as the cause of diseases classified elsewhere
C38.0 Malignant neoplasm of heart
C45.2 Mesothelioma of pericardium
C79.89 Secondary malignant neoplasm of other specified sites
D15.1 Benign neoplasm of heart
D48.7 Neoplasm of uncertain behavior of other specified sites
D48.9 Neoplasm of uncertain behavior, unspecified
D49.81 Neoplasm of unspecified behavior of retina and choroid
E86.0 Dehydration
E86.1 Hypovolemia
E87.71 Transfusion associated circulatory overload
E87.79 Other fluid overload
G45.0 Vertebro-basilar artery syndrome
G45.1 Carotid artery syndrome (hemispheric)
G45.2 Multiple and bilateral precerebral artery syndromes
G45.3 Amaurosis fugax
G45.8 Other transient cerebral ischemic attacks and related syndromes
G46.0 Middle cerebral artery syndrome
G46.1 Anterior cerebral artery syndrome
G46.2 Posterior cerebral artery syndrome
H34.01 Transient retinal artery occlusion, right eye
H34.02 Transient retinal artery occlusion, left eye
H34.03 Transient retinal artery occlusion, bilateral
H34.11 Central retinal artery occlusion, right eye
H34.12 Central retinal artery occlusion, left eye
H34.13 Central retinal artery occlusion, bilateral
H34.211 Partial retinal artery occlusion, right eye
H34.212 Partial retinal artery occlusion, left eye
H34.213 Partial retinal artery occlusion, bilateral
H34.231 Retinal artery branch occlusion, right eye
H34.232 Retinal artery branch occlusion, left eye
H34.233 Retinal artery branch occlusion, bilateral
H34.8111 Central retinal vein occlusion, right eye, with retinal neovascularization
H34.8121 Central retinal vein occlusion, left eye, with retinal neovascularization
H34.8131 Central retinal vein occlusion, bilateral, with retinal neovascularization
H34.821 Venous engorgement, right eye
H34.822 Venous engorgement, left eye
H34.823 Venous engorgement, bilateral
H34.8311 Tributary (branch) retinal vein occlusion, right eye, with retinal neovascularization
H34.8321 Tributary (branch) retinal vein occlusion, left eye, with retinal neovascularization
H34.8331 Tributary (branch) retinal vein occlusion, bilateral, with retinal neovascularization
H53.011 Deprivation amblyopia, right eye
H53.012 Deprivation amblyopia, left eye
H53.013 Deprivation amblyopia, bilateral
H53.021 Refractive amblyopia, right eye
H53.022 Refractive amblyopia, left eye
H53.023 Refractive amblyopia, bilateral
H53.031 Strabismic amblyopia, right eye
H53.032 Strabismic amblyopia, left eye
H53.033 Strabismic amblyopia, bilateral
H53.10 Unspecified subjective visual disturbances
H53.11 Day blindness
H53.121 Transient visual loss, right eye
H53.122 Transient visual loss, left eye
H53.123 Transient visual loss, bilateral
H53.131 Sudden visual loss, right eye
H53.132 Sudden visual loss, left eye
H53.133 Sudden visual loss, bilateral
H53.141 Visual discomfort, right eye
H53.142 Visual discomfort, left eye
H53.143 Visual discomfort, bilateral
H53.15 Visual distortions of shape and size
H53.16 Psychophysical visual disturbances
H53.19 Other subjective visual disturbances
I01.0 Acute rheumatic pericarditis
I01.1 Acute rheumatic endocarditis
I01.2 Acute rheumatic myocarditis
I01.8 Other acute rheumatic heart disease
I02.0 Rheumatic chorea with heart involvement
I05.0 Rheumatic mitral stenosis
I05.1 Rheumatic mitral insufficiency
I05.2 Rheumatic mitral stenosis with insufficiency
I05.8 Other rheumatic mitral valve diseases
I06.0 Rheumatic aortic stenosis
I06.1 Rheumatic aortic insufficiency
I06.2 Rheumatic aortic stenosis with insufficiency
I06.8 Other rheumatic aortic valve diseases
I07.0 Rheumatic tricuspid stenosis
I07.1 Rheumatic tricuspid insufficiency
I07.2 Rheumatic tricuspid stenosis and insufficiency
I07.8 Other rheumatic tricuspid valve diseases
I08.0 Rheumatic disorders of both mitral and aortic valves
I08.1 Rheumatic disorders of both mitral and tricuspid valves
I08.2 Rheumatic disorders of both aortic and tricuspid valves
I08.3 Combined rheumatic disorders of mitral, aortic and tricuspid valves
I08.8 Other rheumatic multiple valve diseases
I09.0 Rheumatic myocarditis
I09.1 Rheumatic diseases of endocardium, valve unspecified
I09.89 Other specified rheumatic heart diseases
I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.4 Non-ST elevation (NSTEMI) myocardial infarction
I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction
I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites
I23.1 Atrial septal defect as current complication following acute myocardial infarction
I23.2 Ventricular septal defect as current complication following acute myocardial infarction
I23.4 Rupture of chordae tendineae as current complication following acute myocardial infarction
I23.5 Rupture of papillary muscle as current complication following acute myocardial infarction
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
I25.3 Aneurysm of heart
I25.41 Coronary artery aneurysm
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris
I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris
I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris
I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris
I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris
I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris
I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm
I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris
I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris
I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm
I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris
I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
I25.82 Chronic total occlusion of coronary artery
I25.83 Coronary atherosclerosis due to lipid rich plaque
I25.84 Coronary atherosclerosis due to calcified coronary lesion
I26.01 Septic pulmonary embolism with acute cor pulmonale
I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
I26.03 Cement embolism of pulmonary artery with acute cor pulmonale
I26.04 Fat embolism of pulmonary artery with acute cor pulmonale
I26.09 Other pulmonary embolism with acute cor pulmonale
I26.90 Septic pulmonary embolism without acute cor pulmonale
I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93 Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale
I26.94 Multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale
I26.95 Cement embolism of pulmonary artery without acute cor pulmonale
I26.96 Fat embolism of pulmonary artery without acute cor pulmonale
I26.99 Other pulmonary embolism without acute cor pulmonale
I28.0 Arteriovenous fistula of pulmonary vessels
I28.1 Aneurysm of pulmonary artery
I31.0 Chronic adhesive pericarditis
I31.1 Chronic constrictive pericarditis
I31.2 Hemopericardium, not elsewhere classified
I31.4 Cardiac tamponade
I31.8 Other specified diseases of pericardium
I33.0 Acute and subacute infective endocarditis
I34.0 Nonrheumatic mitral (valve) insufficiency
I34.1 Nonrheumatic mitral (valve) prolapse
I34.2 Nonrheumatic mitral (valve) stenosis
I34.81 Nonrheumatic mitral (valve) annulus calcification
I34.89 Other nonrheumatic mitral valve disorders
I35.0 Nonrheumatic aortic (valve) stenosis
I35.1 Nonrheumatic aortic (valve) insufficiency
I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency
I35.8 Other nonrheumatic aortic valve disorders
I36.0 Nonrheumatic tricuspid (valve) stenosis
I36.1 Nonrheumatic tricuspid (valve) insufficiency
I36.2 Nonrheumatic tricuspid (valve) stenosis with insufficiency
I36.8 Other nonrheumatic tricuspid valve disorders
I37.0 Nonrheumatic pulmonary valve stenosis
I37.1 Nonrheumatic pulmonary valve insufficiency
I37.2 Nonrheumatic pulmonary valve stenosis with insufficiency
I37.8 Other nonrheumatic pulmonary valve disorders
I38 Endocarditis, valve unspecified
I39 Endocarditis and heart valve disorders in diseases classified elsewhere
I40.0 Infective myocarditis
I40.1 Isolated myocarditis
I40.8 Other acute myocarditis
I41 Myocarditis in diseases classified elsewhere
I42.0 Dilated cardiomyopathy
I42.1 Obstructive hypertrophic cardiomyopathy
I42.2 Other hypertrophic cardiomyopathy
I42.3 Endomyocardial (eosinophilic) disease
I42.4 Endocardial fibroelastosis
I42.5 Other restrictive cardiomyopathy
I42.6 Alcoholic cardiomyopathy
I42.7 Cardiomyopathy due to drug and external agent
I42.8 Other cardiomyopathies
I43 Cardiomyopathy in diseases classified elsewhere
I48.0 Paroxysmal atrial fibrillation
I48.11 Longstanding persistent atrial fibrillation
I48.19 Other persistent atrial fibrillation
I48.20 Chronic atrial fibrillation, unspecified
I48.21 Permanent atrial fibrillation
I48.3 Typical atrial flutter
I48.4 Atypical atrial flutter
I51.0 Cardiac septal defect, acquired
I51.1 Rupture of chordae tendineae, not elsewhere classified
I51.2 Rupture of papillary muscle, not elsewhere classified
I51.3 Intracardiac thrombosis, not elsewhere classified
I51.4 Myocarditis, unspecified
I51.7 Cardiomegaly
I51.81 Takotsubo syndrome
I51.89 Other ill-defined heart diseases
I63.011 Cerebral infarction due to thrombosis of right vertebral artery
I63.012 Cerebral infarction due to thrombosis of left vertebral artery
I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries
I63.02 Cerebral infarction due to thrombosis of basilar artery
I63.031 Cerebral infarction due to thrombosis of right carotid artery
I63.032 Cerebral infarction due to thrombosis of left carotid artery
I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries
I63.09 Cerebral infarction due to thrombosis of other precerebral artery
I63.111 Cerebral infarction due to embolism of right vertebral artery
I63.112 Cerebral infarction due to embolism of left vertebral artery
I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries
I63.12 Cerebral infarction due to embolism of basilar artery
I63.131 Cerebral infarction due to embolism of right carotid artery
I63.132 Cerebral infarction due to embolism of left carotid artery
I63.133 Cerebral infarction due to embolism of bilateral carotid arteries
I63.19 Cerebral infarction due to embolism of other precerebral artery
I63.211 Cerebral infarction due to unspecified occlusion or stenosis of right vertebral artery
I63.212 Cerebral infarction due to unspecified occlusion or stenosis of left vertebral artery
I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries
I63.22 Cerebral infarction due to unspecified occlusion or stenosis of basilar artery
I63.231 Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries
I63.232 Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries
I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries
I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries
I63.323 Cerebral infarction due to thrombosis of bilateral anterior cerebral arteries
I63.333 Cerebral infarction due to thrombosis of bilateral posterior cerebral arteries
I63.343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries
I63.411 Cerebral infarction due to embolism of right middle cerebral artery
I63.412 Cerebral infarction due to embolism of left middle cerebral artery
I63.413 Cerebral infarction due to embolism of bilateral middle cerebral arteries
I63.421 Cerebral infarction due to embolism of right anterior cerebral artery
I63.422 Cerebral infarction due to embolism of left anterior cerebral artery
I63.423 Cerebral infarction due to embolism of bilateral anterior cerebral arteries
I63.431 Cerebral infarction due to embolism of right posterior cerebral artery
I63.432 Cerebral infarction due to embolism of left posterior cerebral artery
I63.433 Cerebral infarction due to embolism of bilateral posterior cerebral arteries
I63.441 Cerebral infarction due to embolism of right cerebellar artery
I63.442 Cerebral infarction due to embolism of left cerebellar artery
I63.443 Cerebral infarction due to embolism of bilateral cerebellar arteries
I63.49 Cerebral infarction due to embolism of other cerebral artery
I63.89 Other cerebral infarction
I65.01 Occlusion and stenosis of right vertebral artery
I65.02 Occlusion and stenosis of left vertebral artery
I65.03 Occlusion and stenosis of bilateral vertebral arteries
I65.1 Occlusion and stenosis of basilar artery
I65.21 Occlusion and stenosis of right carotid artery
I65.22 Occlusion and stenosis of left carotid artery
I65.23 Occlusion and stenosis of bilateral carotid arteries
I65.8 Occlusion and stenosis of other precerebral arteries
I66.01 Occlusion and stenosis of right middle cerebral artery
I66.02 Occlusion and stenosis of left middle cerebral artery
I66.03 Occlusion and stenosis of bilateral middle cerebral arteries
I66.11 Occlusion and stenosis of right anterior cerebral artery
I66.12 Occlusion and stenosis of left anterior cerebral artery
I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries
I66.21 Occlusion and stenosis of right posterior cerebral artery
I66.22 Occlusion and stenosis of left posterior cerebral artery
I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries
I66.3 Occlusion and stenosis of cerebellar arteries
I66.8 Occlusion and stenosis of other cerebral arteries
I67.841 Reversible cerebrovascular vasoconstriction syndrome
I67.848 Other cerebrovascular vasospasm and vasoconstriction
I67.89 Other cerebrovascular disease
I70.0 Atherosclerosis of aorta
I71.010 Dissection of ascending aorta
I71.011 Dissection of aortic arch
I71.012 Dissection of descending thoracic aorta
I71.019 Dissection of thoracic aorta, unspecified
I71.03 Dissection of thoracoabdominal aorta
I71.10 Thoracic aortic aneurysm, ruptured, unspecified
I71.11 Aneurysm of the ascending aorta, ruptured
I71.12 Aneurysm of the aortic arch, ruptured
I71.13 Aneurysm of the descending thoracic aorta, ruptured
I71.21 Aneurysm of the ascending aorta, without rupture
I71.22 Aneurysm of the aortic arch, without rupture
I71.23 Aneurysm of the descending thoracic aorta, without rupture
I71.50 Thoracoabdominal aortic aneurysm, ruptured, unspecified
I71.51 Supraceliac aneurysm of the thoracoabdominal aorta, ruptured
I71.52 Paravisceral aneurysm of the thoracoabdominal aorta, ruptured
I71.60 Thoracoabdominal aortic aneurysm, without rupture, unspecified
I71.61 Supraceliac aneurysm of the thoracoabdominal aorta, without rupture
I71.62 Paravisceral aneurysm of the thoracoabdominal aorta, without rupture
I74.01 Saddle embolus of abdominal aorta
I74.09 Other arterial embolism and thrombosis of abdominal aorta
I74.11 Embolism and thrombosis of thoracic aorta
I74.19 Embolism and thrombosis of other parts of aorta
I74.2 Embolism and thrombosis of arteries of the upper extremities
I74.3 Embolism and thrombosis of arteries of the lower extremities
I74.5 Embolism and thrombosis of iliac artery
I74.8 Embolism and thrombosis of other arteries
I76 Septic arterial embolism
I82.220 Acute embolism and thrombosis of inferior vena cava
I82.221 Chronic embolism and thrombosis of inferior vena cava
I82.3 Embolism and thrombosis of renal vein
I87.1 Compression of vein
I87.301 Chronic venous hypertension (idiopathic) without complications of right lower extremity
I87.302 Chronic venous hypertension (idiopathic) without complications of left lower extremity
I87.303 Chronic venous hypertension (idiopathic) without complications of bilateral lower extremity
I87.391 Chronic venous hypertension (idiopathic) with other complications of right lower extremity
I87.392 Chronic venous hypertension (idiopathic) with other complications of left lower extremity
I87.393 Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity
I95.89 Other hypotension
I95.9 Hypotension, unspecified
I97.0 Postcardiotomy syndrome
I97.110 Postprocedural cardiac insufficiency following cardiac surgery
I97.111 Postprocedural cardiac insufficiency following other surgery
I97.120 Postprocedural cardiac arrest following cardiac surgery
I97.121 Postprocedural cardiac arrest following other surgery
I97.130 Postprocedural heart failure following cardiac surgery
I97.131 Postprocedural heart failure following other surgery
I97.190 Other postprocedural cardiac functional disturbances following cardiac surgery
I97.191 Other postprocedural cardiac functional disturbances following other surgery
I97.710 Intraoperative cardiac arrest during cardiac surgery
I97.711 Intraoperative cardiac arrest during other surgery
I97.790 Other intraoperative cardiac functional disturbances during cardiac surgery
I97.791 Other intraoperative cardiac functional disturbances during other surgery
K55.011 Focal (segmental) acute (reversible) ischemia of small intestine
K55.012 Diffuse acute (reversible) ischemia of small intestine
K55.021 Focal (segmental) acute infarction of small intestine
K55.022 Diffuse acute infarction of small intestine
K55.031 Focal (segmental) acute (reversible) ischemia of large intestine
K55.032 Diffuse acute (reversible) ischemia of large intestine
K55.041 Focal (segmental) acute infarction of large intestine
K55.042 Diffuse acute infarction of large intestine
K68.11 Postprocedural retroperitoneal abscess
M32.11 Endocarditis in systemic lupus erythematosus
N28.0 Ischemia and infarction of kidney
Q20.0 Common arterial trunk
Q20.1 Double outlet right ventricle
Q20.2 Double outlet left ventricle
Q20.3 Discordant ventriculoarterial connection
Q20.4 Double inlet ventricle
Q20.5 Discordant atrioventricular connection
Q20.8 Other congenital malformations of cardiac chambers and connections
Q21.0 Ventricular septal defect
Q21.10 Atrial septal defect, unspecified
Q21.11 Secundum atrial septal defect
Q21.12 Patent foramen ovale
Q21.19 Other specified atrial septal defect
Q21.20 Atrioventricular septal defect, unspecified as to partial or complete
Q21.21 Partial atrioventricular septal defect
Q21.22 Transitional atrioventricular septal defect
Q21.23 Complete atrioventricular septal defect
Q21.3 Tetralogy of Fallot
Q22.0 Pulmonary valve atresia
Q22.1 Congenital pulmonary valve stenosis
Q22.2 Congenital pulmonary valve insufficiency
Q22.3 Other congenital malformations of pulmonary valve
Q22.4 Congenital tricuspid stenosis
Q22.5 Ebstein's anomaly
Q22.6 Hypoplastic right heart syndrome
Q22.8 Other congenital malformations of tricuspid valve
Q23.0 Congenital stenosis of aortic valve
Q23.1 Congenital insufficiency of aortic valve
Q23.2 Congenital mitral stenosis
Q23.3 Congenital mitral insufficiency
Q23.4 Hypoplastic left heart syndrome
Q23.81 Bicuspid aortic valve
Q23.82 Congenital mitral valve cleft leaflet
Q23.88 Other congenital malformations of aortic and mitral valves
Q24.2 Cor triatriatum
Q24.3 Pulmonary infundibular stenosis
Q24.4 Congenital subaortic stenosis
Q24.5 Malformation of coronary vessels
Q24.8 Other specified congenital malformations of heart
Q25.0 Patent ductus arteriosus
Q25.1 Coarctation of aorta
Q25.29 Other atresia of aorta
Q25.3 Supravalvular aortic stenosis
Q25.41 Absence and aplasia of aorta
Q25.42 Hypoplasia of aorta
Q25.43 Congenital aneurysm of aorta
Q25.44 Congenital dilation of aorta
Q25.45 Double aortic arch
Q25.46 Tortuous aortic arch
Q25.47 Right aortic arch
Q25.48 Anomalous origin of subclavian artery
Q25.49 Other congenital malformations of aorta
Q25.5 Atresia of pulmonary artery
Q25.6 Stenosis of pulmonary artery
Q25.71 Coarctation of pulmonary artery
Q25.72 Congenital pulmonary arteriovenous malformation
Q25.79 Other congenital malformations of pulmonary artery
Q25.8 Other congenital malformations of other great arteries
Q26.2 Total anomalous pulmonary venous connection
Q26.3 Partial anomalous pulmonary venous connection
Q26.4 Anomalous pulmonary venous connection, unspecified
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
R06.3 Periodic breathing
R06.83 Snoring
R06.89 Other abnormalities of breathing
R07.2 Precordial pain
R40.4 Transient alteration of awareness
R44.1 Visual hallucinations
R48.3 Visual agnosia
R50.2 Drug induced fever
R50.81 Fever presenting with conditions classified elsewhere
R50.82 Postprocedural fever
R57.0 Cardiogenic shock
R57.1 Hypovolemic shock
R57.8 Other shock
R65.21 Severe sepsis with septic shock
R78.81 Bacteremia
S25.00XA Unspecified injury of thoracic aorta, initial encounter
S25.01XA Minor laceration of thoracic aorta, initial encounter
S25.02XA Major laceration of thoracic aorta, initial encounter
T79.4XXA Traumatic shock, initial encounter
T80.0XXA Air embolism following infusion, transfusion and therapeutic injection, initial encounter
T80.211A Bloodstream infection due to central venous catheter, initial encounter
T80.212A Local infection due to central venous catheter, initial encounter
T80.218A Other infection due to central venous catheter, initial encounter
T80.22XA Acute infection following transfusion, infusion, or injection of blood and blood products, initial encounter
T81.11XA Postprocedural cardiogenic shock, initial encounter
T81.12XA Postprocedural septic shock, initial encounter
T81.19XA Other postprocedural shock, initial encounter
T81.44XA Sepsis following a procedure, initial encounter
T81.718A Complication of other artery following a procedure, not elsewhere classified, initial encounter
T81.72XA Complication of vein following a procedure, not elsewhere classified, initial encounter
T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter
T82.02XA Displacement of heart valve prosthesis, initial encounter
T82.03XA Leakage of heart valve prosthesis, initial encounter
T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter
T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter
T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter
T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter
T82.120A Displacement of cardiac electrode, initial encounter
T82.121A Displacement of cardiac pulse generator (battery), initial encounter
T82.128A Displacement of other cardiac electronic device, initial encounter
T82.129A Displacement of unspecified cardiac electronic device, initial encounter
T82.190A Other mechanical complication of cardiac electrode, initial encounter
T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter
T82.198A Other mechanical complication of other cardiac electronic device, initial encounter
T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter
T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter
T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.818A Embolism due to vascular prosthetic devices, implants and grafts, initial encounter
T82.827A Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.837A Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.847A Pain due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.855A Stenosis of coronary artery stent, initial encounter
T82.857A Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter
T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter
T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter
T86.23 Heart transplant infection
T86.33 Heart-lung transplant infection
T86.812 Lung transplant infection
Z01.30 Encounter for examination of blood pressure without abnormal findings
Z01.31* Encounter for examination of blood pressure with abnormal findings
Z01.82 Encounter for allergy testing
Z01.89 Encounter for other specified special examinations
Z48.21 Encounter for aftercare following heart transplant
Z48.24 Encounter for aftercare following lung transplant
Z48.280 Encounter for aftercare following heart-lung transplant
Z52.89 Donor of other specified organs or tissues
Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID)
Z79.3 Long term (current) use of hormonal contraceptives
Z79.51 Long term (current) use of inhaled steroids
Z79.52 Long term (current) use of systemic steroids
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z86.74 Personal history of sudden cardiac arrest
Z94.1 Heart transplant status
Z94.2 Lung transplant status
Z94.3 Heart and lungs transplant status
Z95.2 Presence of prosthetic heart valve
Z95.3 Presence of xenogenic heart valve
Z95.4 Presence of other heart-valve replacement
Z95.811 Presence of heart assist device
Z98.890 Other specified postprocedural states
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*Report additional diagnosis code to describe the abnormal finding when reporting Z01.31.

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10-CM Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description

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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Note: The contractor has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this article. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Medicare Claims Processing Manual, for further guidance.


Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2024 R6

Article revised and published on 10/24/2024 effective for dates of service on and after 10/01/2024 to reflect the Annual ICD-10-CM Code Updates. The following codes have been added to Group 1 Codes: I26.03, I26.04, I26.95, I26.96, Q23.81, Q23.82, and Q23.88. The following Group 1 Codes have a descriptor revision: I26.93 and I26.94.

02/09/2024 R5

Article revised and published on 04/11/2024 effective for dates of service on and after 02/09/2024. The following ICD-10-CM codes have been added to Group 1 Codes that Support Medical Necessity: B95.61, B95.62, B95.7, B95.8, I51.3, and R78.81. This revision is in response to an inquiry. Minor formatting changes have been made throughout the article.

10/01/2023 R4

Article revised and published on 10/26/2023 effective for dates of service on and after 10/01/2023 to reflect the Annual ICD-10-CM Code Updates. The following codes in 'Group 1 codes' have been revised: I71.51, I71.52, I71.61 and I71.62.

10/01/2022 R3

Article revised and published on 10/20/2022 effective for dates of service on and after 10/01/2022 to reflect the Annual ICD-10-CM Code Updates. The following ICD-10-CM codes have been added to the ICD-10-CM Codes that Support Medical Necessity section of the article: I34.81, I34.89, I71.010, I71.011, I71.012, I71.019, I71.10, I71.11, I71.12, I71.13, I71.21, I71.22, I71.23, I71.50, I71.51, I71.52, I71.60, I71.61, I71.62, Q21.10, Q21.11, Q21.12, Q21.19, Q21.20, Q21.21, Q21.22, Q21.23 to ‘Group 1 Codes’. The following ICD-10-CM codes have been deleted and therefore have been removed from the Codes that Support Medical Necessity in the article: I34.8, I71.01, I71.1, I71.2, I71.5, I71.6, Q21.1, Q21.2 from ‘Group 1 Codes’. The reference to the Social Security Act Standard has been added to the ‘CMS National Coverage Policy’ section and ‘Documentation Requirements’ have been added to the article along with formatting changes.

10/01/2019 R2

Article revised and published effective for dates of service on and after 10/01/2019 to add Asterisk Explanation to ICD-10 Group 1 Code Z01.31*.

10/01/2019 R1

Article revised and published on 10/17/2019 effective for dates of service on or after 10/01/2019 to reflect the annual ICD-10-CM Code updates. The follwing ICD-10-CM codes have been deleted from Group 1: I48.1 and I48.2. The following ICD-10-CM codes have been added to Group 1: I48.11, I48.19, I48.20, I48.21, I26.93 and I26.94. System changes have been made to our articles in response to CMS Change Request 10901. The Coding Section has been reordered and new sections for CPT/HCPCS Modifiers and Other Coding Information have been added.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L35016 - Transesophageal Echocardiography (TEE)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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CMS Manual Explanations URLs
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Updated On Effective Dates Status
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