Local Coverage Determination (LCD)

B-Type Natriuretic Peptide (BNP)

L33267

Expand All | Collapse All
Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L33267
Original ICD-9 LCD ID
Not Applicable
LCD Title
B-Type Natriuretic Peptide (BNP)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/08/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2024, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution, or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

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

Internet Only Manual (IOM) Citations: 

  • CMS IOM Publications 100-02, Medicare Benefit Policy Manual,
    • Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 16, Laboratory Services
    • Chapter 23, Section 40 Clinical Diagnostic Laboratory Fee Schedule
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD 

Social Security Act (Title XVIII) Standard References:  

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Federal Register References: 

  • Code of Federal Regulations: (CFR), title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests: Conditions

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

History/Background and/or General Information

Congestive Heart Failure (CHF) is characterized by a progressive activation of the neurohormonal systems that control vasoconstriction and sodium retention; the activation of these systems plays a role in its pathogenesis and progression. As the heart fails, B-Type Natriuretic Peptide (BNP), a cardiac neurohormone is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. Used in conjunction with other clinical information, rapid measurement of BNP is useful in establishing or excluding the diagnosis and assessment of severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated. This test is also used to predict the long-term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. For the purposes of this LCD, the total and N terminal assays are both acceptable.

Covered Indications

B-Type Natriuretic Peptide (BNP) measurements will be considered medically reasonable and necessary to establish or exclude the diagnosis and assessment of severity of CHF in patients with acute dyspnea when used in combination with other medical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography (ECG). Rapid measurement of BNP concentration in the blood appears to be a sensitive and specific test for differentiating patients with CHF from primary pulmonary causes of dyspnea in acute care settings.

  • Plasma BNP levels are significantly increased in CHF patients with or without concurrent lung disease compared with patients with primary lung disease.
  • Plasma BNP levels are significantly increased in CHF patients presenting with acute dyspnea compared with patients presenting with acute dyspnea due to other causes.
  • BNP levels are also useful for risk stratification (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina).

Limitations

BNP measurements must be analyzed in conjunction with standard diagnostic tests, the medical history, and clinical findings; its efficacy as a stand-alone test has not yet been established. 

Additional investigation is required to further define the diagnostic value of plasma BNP in monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure. Therefore, BNP measurements for monitoring and management of CHF are not a covered service.

Generally, it is not expected that this test would be performed more than four times in a year.

BNP measurements are not a covered service when performed as a routine screening procedure, in the absence of documentation of clinical findings in the patient’s medical record indicating suspected CHF, or for monitoring and management of CHF. 

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

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

Please accept the License to see the codes.

N/A

CPT/HCPCS Codes

Please accept the License to see the codes.

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Please refer to the Local Coverage Article: Billing and Coding: B-Type Natriuretic Peptide (BNP) (A57649) for documentation requirements that apply to the reasonable and necessary provisions outlined in this LCD.

Utilization Guidelines

Please refer to the Local Coverage Article: Billing and Coding: B-Type Natriuretic Peptide (BNP) (A57649) for utilization guidelines that apply to the reasonable and necessary provisions outlined in this LCD.

Sources of Information

First Coast Service Options, Inc. reference LCD number(s) – L28773, L29065, L29083

Baker, D., Chin, M., Cinquegrani, M., Feldman, A., Francis, G., Ganiats, T., Goldstein, S., Gregoratos, G., Jessup, M., Noble, R., Packer, M., Silver, M., & Stevenson, L. (2001). ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: Executive summary. Journal of the American College of Cardiology, 38(7), 2101-2113.

Bettencourt, P., Ferreira, A., Dias, P., Castro, A., Martins, L., & Cerqueira-Gomes, M. (1999). Evaluation of brain natriuretic peptide in the diagnosis of heart failure. Cardiology, 93, 19-25.

Cheng, V., Kazanagra, R., Garcia, A., Lenert, L., Krishnaswamy, P., Gardetto, N., Clopton, P., Maisel, A. (2001). A rapid bedside test for B-type peptide predicts treatment outcomes in patients admitted for decompensated heart failure: A pilot study. Journal of the American College of Cardiology, 37(2), 386-391.

Collins, S., Ronan-Bentle, S., Storrow, A. (2003). Diagnostic and prognostic usefulness of natriuretic peptides in emergency department patients with dyspnea. Annals of Emergency Medicine. 41(4), 532-545.

Dao, Q., Krishnaswamy, P., Kazanegra, R., Harrison, A., Amirnovin, R., Lenert, L., Clopton, P., Alberto, J., Hlavin, P., & Maisel, A. (2001). Utility of B-type natriuretic peptide in the diagnosis of congestive heart failure in an urgent-care setting. Journal of the American College of Cardiology, 37(2), 379-385.

DeLemos, J., Morrow, D., Bentley, J., Omland, B., Sabatine, M., McCabe, C., Hall, B., Cannon, C., Brauwald, E. (2001). The prognostic value of B-type natriurietic peptide in patients with acute coronary syndromes. New England Journal of Medicine, 345(14), 1014-1021.

Kazanegra, R., Cheng, V., Garcia, A., Krishnaswamy, P., Gardetto, N., Clopton, P., & Maisel, A. (2001) A rapid test for B-type natriuretic peptide correlates with falling wedge pressures in patients treated for decompensated heart failure: A pilot study. Journal of Cardiac Failure, 7(1), 21-29.

Kuster, G., Tanner, H., Printzen, G., Suter, T., Mohacsi, P. & Hess, O. (2003). B-type natriuretic peptide for diagnosis and treatment of congestive heart failure. Swiss Medical Weekly, 133, 623-628.

Lubien, E., DeMaria, A., Krishnaswamy, P., Clopton, P., Koon, J., Kazanegra, R., Gardetto, N., Wanner, E., & Maisel, A. (2002). Utility of B-natriuretic peptide in detecting diastolic dysfunction: Comparison with doppler velocity recordings. Circulation, 105(5), 595-601.

Mair, J., Hammerer-Lercher, A., & Puschendorf, B. (2001). The impact of cardiac natriuretic peptide determination of the diagnosis and management of heart failure. Clin. Lab., 39(7), 571-588.

Maisel, A., Koon, J., Krishnaswamy, P., Kazenegra, R., Clopton, P., Gardetto, N., Morrisey, R., Garcia, A., Chiu, A., & De Maria, A. (2001). Utility of B-natriuretic peptide as a rapid, point-of-care test for screening patients undergoing echocardiography to determine left ventricular dysfunction. American Heart Journal, 141(3), 367-374.

Maisel, A., Krishnaswamy, P., Nowak, R., McCord, J., Hollander, J., Duc, P., Omland, T., Storrow, A., Abraham, W., Wu, A., Clopton, P., Steg, P., Westheim, A., Knudsen, C., Perez, A., Kazanegra, R., Herrmann, H., & McCullough, P. (2002). Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. The New England Journal of Medicine, 347, 161-167.

McCullough, P., Nowak, R., McCord, J., Hollander, J., Herrmann, H., Steg, P., Duc, P., Westheim, A., Omland, T., Knudsen, W., Storrow, A., Abraham, W., Lamba, S., Wu, A., Perez, A., Clopton, P., Krishnaswamy, P., Kazanegra, R., Maisel, A. (2002). B-type natriuretic peptide and clinical judgment in emergency diagnosis of heart failure. Circulation, 106(4), 416-422.

McNairy, M., Gardetto, N., Clopton, P., Garcia, A., Krishnaswamy, P., Kazanegra, R., Ziegler, M., & Maisel, A. (2002). Stability of B-type natriuretic peptide levels during exercise in patients with congestive heart failure: Implications for outpatient monitoring with B-type natriuretic peptide. American Heart Journal, 143(3), 406-411.

Morrison, L., Harrison, A., Krishnaswamy, P., Kazanegra, R., Clopton, P., & Maisel, A. (2002). Utility of a rapid B-natriuretic peptide assay in differentiating congestive heart failure from lung disease in patients presenting with dyspnea. Journal of the American College of Cardiology, 39(2), 201-209.

Peacock, F. (2002). The B-type natriuretic peptide assay: A rapid test for heart failure. Cleveland Clinic Journal of Medicine. 69(3), 243-251.

Remme, W., & Swedberg, K. (2001). Guidelines for the diagnosis and treatment of chronic heart failure: Task force for the diagnosis and treatment of chronic heart failure, European society of cardiology. European Heart Journal, 22(17), 1527-1560.

Vogeser, M., & Jacob, K. (2001). B-type natriuretic peptide (BNP)-Validation of an immediate response assay. Clin. Lab., 47, 29-33.

Wieczorek, S., Wu, A., Christenson, R., Krishnaswamy, P., Gottlieb, S., Rosano, T., Hager, D., Gardetto, N., Chiu, A., Bailly, K., & Maisel, A. (2002). A rapid B-type natriuretic peptide assay accurately diagnoses left ventricular dysfunction and heart failure: A multicenter evaluation. American Heart Journal, 144, 834-839.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
01/08/2019 R5

Revision Number: 3
Publication: November 2019 Connection
LCR A/B2019–075

Explanation of Revision: Based on Change Request (CR) 10901, The LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions ( “Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10–CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act, Code of Federal Regulations, and IOM reference sections were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.

  • Other (Revision based on CR 10901)
10/01/2017 R4

10/02/2018:  This LCD version is approved to allow local coverage documents to be related to the LCD.

  • Other
10/01/2017 R3

Revision Number: 2

Publication: September 2017 Connection 

LCR A/B2017-038

Explanation of Revision: Based on CR 10153 (Annual 2018 ICD-10-CM Update) the LCD was revised. Descriptor revised for ICD-10-CM diagnosis code I50.1.  Added ICD-10-CM diagnosis code I21.9, I21.A1-I21.A9, I50.810-I50.89 and R06.03. The effective date of this revision is based on date of service.

 

10/01/2017:  At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice.  This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To ICD-10-CM Code Changes
05/12/2017 R2

Revision Number: 1 Publication: June 2017 Connection LCR A/B2017-023


Explanation of Revision: Based on CR 8776, the following verbiage was removed from the “CPT/HCPCS Codes” section of the LCD: “Per CR 8572, beginning in CY 2014, payment for most laboratory tests (except for molecular pathology tests) will be packaged under the OPPS, therefore the clinical laboratory tests listed below, for TOB 13X (outpatient hospital), are packaged in this setting.” The effective date of this revision is for claims processed on or after 05/12/2017,  for dates of service on or after 01/01/2014.

  • Provider Education/Guidance
10/01/2015 R1 03/04/15 - - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.
  • Provider Education/Guidance
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A57649 - Billing and Coding: B-Type Natriuretic Peptide (BNP)
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
11/21/2019 01/08/2019 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

N/A

Read the LCD Disclaimer