The information in this Supplemental Instructions Article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA).
CCTA Requirements
The patient shall have a medically indicated CCTA and meet all requirements for Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA). AI-QCT/AI-CPA shall not be performed until after the base study (CCTA) has been completed and interpreted.
As this service constitutes post-procedure analysis of a previously performed study (CCTA), the name and NPI of the referring/ordering physician that submitted imaging data for AI-QCT/AI-CPA review must be reported on the claim.
General Guidelines for Claims submitted to Part A or Part B MAC:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.
If the test is ordered prior to the results of CCTA being available and the patient is not eligible for AI-QTC/AI-CPA per the LCD the study will be non-covered.
Advance Beneficiary Notice of Non-coverage (ABN) Modifier Guidelines
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.
Effective from April 1, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, as appropriate.
The –GA modifier (“Waiver of Liability Statement Issued as Required by Payer Policy”) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.
Modifier GX (“Notice of Liability Issued, Voluntary Under Payer Policy”) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, Part A MAC systems will automatically deny the services.
The –GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.
Guidelines for Documentation and Utilization:
Documentation Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (Please see " Coverage Guidance, Limitations, and Reasonable and Necessary Criteria").
The patient’s medical record shall document all of the following:
- History and physical exam with detail sufficient to assess pre-test probability for CAD
- Description of symptoms consistent with stable ischemic heart disease.
- The clinical findings that led to the initial performance of the CCTA, and the CCTA must be completed and interpreted before the performance of AI-QCT/AI-CPA.
- The clinical indication for the addition of AI-QCT/AI-CPA must be documented.
- Coronary Computed Tomographic Angiography report
- AI-QCT/AI-CPA analysis report
