Contractor Information

Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s) National Government Services, Inc. MAC - Part A 06101 - MAC A J - 06 Illinois National Government Services, Inc. MAC - Part B 06102 - MAC B J - 06 Illinois National Government Services, Inc. MAC - Part A 06201 - MAC A J - 06 Minnesota National Government Services, Inc. MAC - Part B 06202 - MAC B J - 06 Minnesota National Government Services, Inc. MAC - Part A 06301 - MAC A J - 06 Wisconsin National Government Services, Inc. MAC - Part B 06302 - MAC B J - 06 Wisconsin National Government Services, Inc.

A and B and HHH MAC 13101 - MAC A J - K Connecticut National Government Services, Inc.

A and B and HHH MAC 13102 - MAC B J - K Connecticut National Government Services, Inc. A and B and HHH MAC 13201 - MAC A J - K New York - Entire State National Government Services, Inc. A and B and HHH MAC 13202 - MAC B J - K New York - Downstate National Government Services, Inc. A and B and HHH MAC 13282 - MAC B J - K New York - Upstate National Government Services, Inc. A and B and HHH MAC 13292 - MAC B J - K New York - Queens National Government Services, Inc. A and B and HHH MAC 14111 - MAC A J - K Maine National Government Services, Inc. A and B and HHH MAC 14112 - MAC B J - K Maine National Government Services, Inc.

A and B and HHH MAC 14211 - MAC A J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14212 - MAC B J - K Massachusetts National Government Services, Inc. A and B and HHH MAC 14311 - MAC A J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14312 - MAC B J - K New Hampshire National Government Services, Inc. A and B and HHH MAC 14411 - MAC A J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14412 - MAC B J - K Rhode Island National Government Services, Inc. A and B and HHH MAC 14511 - MAC A J - K Vermont National Government Services, Inc.

A and B and HHH MAC 14512 - MAC B J - K Vermont LCD ID Original Effective Date Local Coverage Determination (LCD): Transesophageal Echocardiography (TEE) (L33579) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Back to Top LCD Information Document Information Printed on 10/27/2018. Page 1 of 30

L33579 Original ICD-9 LCD ID L27381 LCD Title Transesophageal Echocardiography (TEE) Proposed LCD in Comment Period N/A Source Proposed LCD N/A AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright 2002-2018 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. 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. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association.

UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association (“AHA”), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA.” Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2018 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.

NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Section 1862(a)(7) of Title XVIII of the Social Security Act excludes routine physical examination, unless otherwise covered by statute.

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80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests 100 General Billing Requirements 30.4 Cardiovascular System (Codes 92950-93799) 20 Payment conditions for radiology services 1. When needed to assess the etiology of mitral regurgitation 2. When needed to assist in the decision making: mitral valve repair vs. replacement Code of Federal Regulations: 42 CFR, Section 410.32, indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements) and the results must be used in the management of the patient.

42 CFR, Section 410.33c, describes qualifications required for non-physician practitioners used by an IDTF. CMS Publications: CMS Publication 100-02, Medicare Coverage Issues Manual, Chapter 15: CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9: CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12: CMS Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 13: National CCI Manual, version 13.3, Chapter II: CCI editing for anesthesia services; accessible at http://www.cms.hhs.gov/NationalCorrectCodInitEd/ Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract: Transesophageal echocardiography (TEE) is ultrasonic examination of the heart performed by placing the transducer in the esophagus which allows different views of the heart than transthoracic echocardiography (TTE).

TEE is particularly useful for posterior structures, such as the pulmonary veins, left atrium, and mitral valve and provides better visualization of the aortic root, valve and the ascending and descending aorta and arch. TEE is frequently performed because TTE was not technically adequate. In addition, there are a number of medical conditions for which TEE is preferred over transthoracic echocardiography (see indications below). TEE is considered medically necessary when there is a reasonable expectation that it will both provide information not available with TTE or other less invasive forms of imaging and significantly contribute to management decisions regarding treatment of the patient.

In order to qualify as a valid echocardiographic service, the study must be done for an accepted clinical indication by a properly trained examiner and must include a permanent record of the findings, data sufficient to support the conclusions and an appropriate interpretation and written report. This policy addresses the medically necessary and appropriate application of TEE. Transthoracic echocardiography (TTE) is the subject of a separate policy statement. Indications: Mitral valve disease: TEE is indicated for the following: Printed on 10/27/2018. Page 3 of 30

1.

When the suspicion of endocarditis is high (persistent febrile state, negative cultures, preexistent valvular pathology) and TTE does not document endocarditis. TEE may define small vegetative masses and more completely delineate local complications (e.g., ring abscesses, aneurysm, fistulae). 2. Re-evaluation in complex endocarditis; 3. Evaluation of bacteremia without known source; 4. Evaluation of suspected or actual prosthetic valve endocarditis otherwise obscured because of reverberations and other image artifacts related to mechanical or other non-native valves during TTE. 1. Evaluation of the left atrium and atrial appendage for clot, when clot is not visualized on TTE; 2.

Evaluation for an ASD, patent foramen ovale or atrial septal aneurysm with clot; and 3. Evaluation of the mitral valve in patients with a history of emboli. 1. Visualization of left atrial masses when needed to provide therapeutic direction (cystic vs. solid, attachment, infiltration); 2. When cardiac mass lesions (including tumors on cardiac valves) are suspect and cannot be visualized on TTE, and TEE is needed for development of a management strategy; 3. To assess pericardial effusion when surface studies do not provide adequate information. "The risk of pericardiocentesis may be reduced by the use of echocardiographic guidance and monitoring of needle aspiration, particularly for loculated or small effusions." (ACC/AHA/ASE 2003 Guideline Update, pg.

39). 1. TEE may be indicated when adequate visualization of the aortic root is not sufficient with TTE. 2. TEE may be indicated for identification of aortic dissection, aortic ulceration, atherosclerotic plaque, and mural thrombotic material.

3. TEE has a particularly high degree of sensitivity and specificity for aortic dissection. TEE is the technique that is indicated in examination of the entire aorta, especially in emergency situations. 4. Because descending thoracic aortic aneurysms are difficult to visualize using TTE, TEE is recommended for this condition. 5. Visualization of the superior vena cava and diagnosing various congenital and acquired abnormalities, such as vena caval thrombosis; 6. Visualization of the proximal inferior vena cava, vena caval dilation and detection of thrombosis or extension of tumors from the inferior vena cava to the right-heart chambers; 7.

Visualization of all four pulmonary veins; 8. Evaluation of the heart and great vessels following blunt trauma to the chest (e.g., rupture or transsection of the aorta, acute dissection, hematoma, etc.) 9. When needed to assist in the decision making prior to aortic valve operative intervention. 1. Patients with congenital heart disease postoperatively where fibrosis, echo opaque patches and prostheses, inadequate penetration, and acoustical shadowing can result in incomplete TTE data; 2. Patients in which TTE is technically inadequate or anatomic definition is incomplete; 3. Patients in whom a more precise definition of atrial, outflow tract and proximal pulmonary vascular anomalies by TEE can be critical to management strategies; Endocarditis: TEE is indicated for the following: Valvular Prostheses (mechanical and bioprostheses): TEE is indicated in the evaluation of suspected prosthetic valve dysfunction when therapeutic decisions are critical and TTE is inconclusive and/or when the left atrium must be well-visualized.

TEE is not routinely indicated in all patients with prosthetic valves. Suspected Cardiac Thrombi and Emboli: TEE is indicated for the following: Cardiac/Pericardial Masses and Other Pericardial Disease: TTE and TEE have comparable sensitivity in the assessment of right heart masses. Therefore, TEE is indicated for the following: Aortic Pathological Conditions and Diseases of the Great Vessels: Congenital Heart Disease: TEE is indicated for the following: Printed on 10/27/2018. Page 4 of 30

4. To assess complications of congenital heart surgery, visualization of shunt flow across atrial-septal defects, guidance of clamshell device to close atrial-septal defects, diagnosis of cor triatriatum, and detection of pulmonary valve abnormalities. 1. Management of the critically ill patient when TTE is otherwise contraindicated (e.g., chest or other major trauma) or inadequate (e.g., patient on a ventilator or with COPD, or in postoperative patients who are unable to be positioned for TTE); 2. Patients with persistent hypoxemia having suspected right-to-left shunt; 3. Patients with complications of myocardial infarction (ruptured septum, papillary muscle, or free wall); 4.

Hemodynamically unstable patients in whom TTE images are suboptimal; 5. Evaluation of brain-dead patients being considered as cardiac donors; 6. Persistent unexplained fever when endocarditis or myocardial abscess is suspected and TTE is non- diagnostic.

1. Guidance during percutaneous cardiac interventions such as during the creation of shunts, placement of septation devices, valvuloplasty procedures, endomyocardial biopsy, electrophysiologic studies/procedures, placement of septal or atrial appendage occluders or during percutaneous valve replacement; 2. Intraoperative evaluation to assess prosthetic or repaired/reconstructed valve function, or the integrity/function of complex congenital heart repairs; 3. Intraoperative evaluation to assess the integrity of the cardiopulmonary circulation in patients during lung or heart-lung transplants; and 4.

Intraoperative assessment for presence and/or severity of outflow tract obstruction or presence/repair of an intracardiac shunt; 5. Intraoperative assessment of wall motion abnormalities in the case of acute deterioration in the patient's status, once the chest has been closed; 6. Only TEE done for specific diagnostic purposes may be separately payable during intraoperative use (TEE used for monitoring purposes is not separately payable). The results of the test must be used in making management decisions on the patient's intraoperative treatment. A covered service must include a complete interpretation/report by the performing physician, and must be available if requested.

1. Spectral Doppler echocardiography and Doppler color flow-velocity mapping (93320, 93321, 93325) may be necessary in addition to an echocardiogram when the examination could contribute significant information to the patient's condition or treatment plan (code 93306 should be used when Doppler is combined with a complete echocardiogram). Typically, Doppler is indicated in the evaluation of some heart murmurs, valvular problems, shunts, suspected congenital heart disease, complications of myocardial infarction, or cardiomyopathy. Doppler should be medically necessary for the evaluation and management of the patient.

2. "Color/spectral Doppler may not be useful or appropriate in certain relatively small and well-defined patient populations when there is a recent comprehensive examination and the test is being ordered for re -evaluation of a limited problem." (ASE comment). 3. The use of the Doppler is inherent in the ultrasonic cardiac evaluation. However, if the test reports fail to document the use of this technique to assess these structures and function (e.g., measurement of valvular insufficiency or stenosis, myocardial diastolic function, etc. as described by the ASE), or if the medical records fail to document that the examination was "clinically necessary" (e.g., follow-up of pericardial effusion size) then the Doppler portion of the test may be considered medically unnecessary and denied.

1. The pre-operative planning of valve repair for multiple etiologies of mitral regurgitation; 2. Assessment of mitral stenosis and in the accurate calculation of mitral valve area; 3. Pre-operative planning for diagnosis and treatment of atrial septal defects; Critically Ill Patients: TEE is indicated for the following: Interventional and Surgical TEE: TEE is indicated for the following: Doppler Color Flow Velocity Mapping: 3-Dimensional Echocardiography When billed with TEE (93312, 93314, 93315, 93317, C8925, C8926), it is indicated for: Printed on 10/27/2018. Page 5 of 30

4. Pre-operative and intraoperative planning for interventional cardiac procedures (e.g., transcatheter placement of occluders for atrial septal defects or patent foramen ovales, or paravalvular dehiscence or leaks; 5. Intraoperative mapping for atrial ablation procedures. 6. The evaluation of tricuspid valve disease. 1. Requiring urgent (not emergent) cardioversion for whom extended pre-cardioversion anticoagulation is not desirable; 2. Who have had prior cardioembolic events thought to be related to intra-atrial thrombus; 3. For whom anticoagulation is contraindicated and for whom a decision about cardioversion will be influenced by TEE results; 4.

For whom intra-atrial thrombus has been demonstrated in previous TEE. (ACC/AHA/ASE 2003 Guideline Update, pgs. 49-50) • The service is performed by a physician; or While three-dimensional echocardiography may provide improved calculation of volume when compared to 2D echocardiography, its value in affecting clinical outcomes is not yet proven and it is therefore not medically necessary.

TEE is indicated for cardioversion in patients: Limitations: Screening examinations to identify structural cardiac abnormalities in the absence of established diagnoses, signs or symptoms, are not considered reasonable and necessary. TEE does not provide incremental information over that obtained by TTE in the serial assessment and management of pericardial pathology. Therefore, it will not be covered, unless there are loculated posterior effusions or adequate visualization of the pericardium is not possible by TTE. In general, TTE provides accurate and serial noninvasive assessment of global and regional left ventricular function.

Unless TTE is technically inadequate and clinical data is insufficient for a management decision, TEE will not be covered. Transthoracic echocardiographic assessment of left ventricular function is considered preferable to TEE in all other circumstances.

Intraoperative TEE (93318) is reimbursable to a cardiologist or other physician who is not part of the surgical/anesthesia team but only when performed as a diagnostic test and not for monitoring purposes (TEE for intraoperative monitoring is included in the anesthesia care). In aortic root dilation in Marfan Syndrome or other connective tissue syndromes, the ACC AHA/ASE 2003 Guideline Update recommends TTE over TEE as the first choice for examination. "TEE should only be used if the examination is incomplete or additional information is needed." (pg. 42.) In most patients with valvular prostheses TTE provides diagnostic functional information and noninvasive serial follow-up.

However, in some patients, acoustical shadowing can decrease data acquisition. If TTE provides adequate information for diagnosis and management, then TEE is not covered. The medical record should document any need for additional information.

In general, TTE can reliably diagnose or exclude evidence of potentially embolic material located in a ventricle. The TEE may complement TTE, particularly to assess for left atrial thrombus and patent foramen ovale or atrial septal aneurysm. The additional information that can be provided by TEE should be reasonably anticipated to be of therapeutic relevance before the patient is subjected to TEE, otherwise the TEE is not covered. Training Requirements: Medicare expects a satisfactory level of competence from providers who submit claims for services rendered for these services to be considered medically necessary.

Tests performed by providers not meeting these levels of competence will be denied.

The acceptable levels of competence are outlined as follows: a. For the technical portion, an acceptable level of competence is fulfilled when the image acquisition is obtained under any one of the following conditions: Printed on 10/27/2018. Page 6 of 30

• The technical portion of the service is performed by a technician who is credentialed as either a Registered Diagnostic Cardiac Sonographer (RDCS) through the American Registry of Diagnostic Medical Sonographers or as a Registered Cardiac Sonographer (RCS) through the Cardiovascular Credentialing International; or • Any non-physician personnel used by an IDTF to perform tests must demonstrate the basic qualifications to perform the tests in question and have training and proficiency as evidenced by licensure or certification by the appropriate State health or education department.

In the absence of a State licensing board, the technician must be certified by an appropriate national credentialing body. The IDTF must maintain documentation available for review that these requirements are met. (42 CFR, Section 410.33c) • b. For the professional portion, an acceptable level of competence is fulfilled when the interpretation is performed by a physician meeting any one of the following requirements: • The physician is board certified in Cardiovascular Diseases or Perioperative Transesophageal Echocardiography (National Board of Echocardiography); or • The physician has Level II training in transesophageal echocardiography (including documentation of the performance of 25 esophageal intubations and 50 supervised interpretations), as defined by the American College of Cardiology/American Heart Association/ American College of Physicians Task Force on Clinical Competence in Echocardiography, or the equivalent of Level II training as set forth in that document, or has been credentialed for this procedure by the hospital where the physician performs this service.

• The submission of claims for transesophageal echocardiography will be considered an attestation that both the technical and professional components of the service were provided within the context of the above stated credentials. The requirements have been in effect in New York and Connecticut since prior to 2011 and are effective in Illinois (for Part B providers), Maine, Massachusetts, Minnesota, New Hampshire, Rhode Island, Vermont and Wisconsin (for Part B providers) as of January 1, 2017. 011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 071x Clinic - Rural Health 073x Clinic - Freestanding 077x Clinic - Federally Qualified Health Center (FQHC) Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A Back to Top Coding Information 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 policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

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085x Critical Access Hospital 0480 Cardiology - General Classification 0483 Cardiology - Echocardiology 0521 Freestanding Clinic - Clinic Visit by Member to RHC/FQHC 0522 Freestanding Clinic - Home Visit by RHC/FQHC Practitioner 0524 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF or Skilled Swing Bed in a Covered Part A Stay 0525 Freestanding Clinic - Visit by RHC/FQHC Practitioner to a Member in a SNF (not in a Covered Part A Stay) or NF or ICF MR or Other Residential Facility 0527 Freestanding Clinic - Visiting Nurse Service(s) to a Member's Home when in a Home Health Shortage Area 0528 Freestanding Clinic - Visit by RHC/FQHC Practitioner to Other non-RHC/FQHC site (e.g.

Scene of Accident) 0960 Professional Fees - General Classification 0969 Professional Fees - Other Professional Fee 0972 Professional Fees - Radiology - Diagnostic 0982 Professional Fees - Outpatient Services 0983 Professional Fees - Clinic 76376 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION 76377 3D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION 93312 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT 93313 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY 93314 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL-TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY 93315 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT 93316 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY 93317 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY 93318 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 policy, 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 policy should be assumed to apply equally to all Revenue Codes.

Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.

CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: Printed on 10/27/2018. Page 8 of 30

ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE 93321 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING) 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) C8925 TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT C8926 TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR CONGENITAL CARDIAC ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT C8927 TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, FOR MONITORING PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2- DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO THERAPEUTIC MEASURES ON AN IMMEDIATE TIME BASIS ICD-10 Codes Description A02.1 Salmonella sepsis A18.84 Tuberculosis of heart A22.7 Anthrax sepsis A26.7 Erysipelothrix sepsis A32.7 Listerial sepsis 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 A40.9 Streptococcal sepsis, unspecified 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 A41.2 Sepsis due to unspecified staphylococcus A41.3 Sepsis due to Hemophilus influenzae A41.4 Sepsis due to anaerobes A41.50 Gram-negative sepsis, unspecified 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 A41.9 Sepsis, unspecified organism A42.7 Actinomycotic sepsis A52.01 Syphilitic aneurysm of aorta ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: The correct use of an ICD-10-CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. The following diagnoses are covered for CPT codes 93312, 93313, 93314 and C8925.

(When reporting add-on CPT codes 93320, 93321 and 93325, the same ICD-10-CM code should be used as that used for the base code to which it is attached): Group 1 Codes: Printed on 10/27/2018. Page 9 of 30

ICD-10 Codes Description A52.02 Syphilitic aortitis A54.86 Gonococcal sepsis B37.7 Candidal sepsis C38.0 Malignant neoplasm of heart C45.2 Mesothelioma of pericardium C79.89 Secondary malignant neoplasm of other specified sites C79.9 Secondary malignant neoplasm of unspecified site D15.1 Benign neoplasm of heart D48.7 Neoplasm of uncertain behavior of other specified sites D49.89 Neoplasm of unspecified behavior of other specified sites G06.0 Intracranial abscess and granuloma G06.1 Intraspinal abscess and granuloma G45.0 Vertebro-basilar artery syndrome G45.1 Carotid artery syndrome (hemispheric) G45.2 Multiple and bilateral precerebral artery syndromes G45.8 Other transient cerebral ischemic attacks and related syndromes G45.9 Transient cerebral ischemic attack, unspecified G46.0 Middle cerebral artery syndrome G46.1 Anterior cerebral artery syndrome G46.2 Posterior cerebral artery syndrome I01.1 Acute rheumatic endocarditis I01.2 Acute rheumatic myocarditis 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 I05.9 Rheumatic mitral valve disease, unspecified 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 I08.9 Rheumatic multiple valve disease, unspecified I09.0 Rheumatic myocarditis I09.1 Rheumatic diseases of endocardium, valve unspecified I09.89 Other specified rheumatic heart diseases I09.9 Rheumatic heart disease, unspecified I23.0 Hemopericardium as current complication following acute myocardial infarction I23.1 Atrial septal defect as current complication following acute myocardial infarction I23.2 Ventricular septal defect as current complication following acute myocardial infarction I23.3 Rupture of cardiac wall without hemopericardium 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 I23.6 Thrombosis of atrium, auricular appendage, and ventricle as current complications following acute myocardial infarction I23.7 Postinfarction angina I23.8 Other current complications following acute myocardial infarction I25.3 Aneurysm of heart I25.41 Coronary artery aneurysm I25.42 Coronary artery dissection I25.82 Chronic total occlusion of coronary artery I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus 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 I26.99 Other pulmonary embolism without acute cor pulmonale Printed on 10/27/2018.

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ICD-10 Codes Description I28.0 Arteriovenous fistula of pulmonary vessels I28.1 Aneurysm of pulmonary artery I31.4 Cardiac tamponade 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 I34.8 Other nonrheumatic mitral valve disorders I34.9 Nonrheumatic mitral valve disorder, unspecified 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 I35.9 Nonrheumatic aortic valve disorder, unspecified I36.1 Nonrheumatic tricuspid (valve) insufficiency I36.2 Nonrheumatic tricuspid (valve) stenosis with insufficiency I36.8 Other nonrheumatic tricuspid valve disorders I36.9 Nonrheumatic tricuspid valve disorder, unspecified 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 I37.9 Nonrheumatic pulmonary valve disorder, unspecified I38 Endocarditis, valve unspecified I39 Endocarditis and heart valve disorders in diseases classified elsewhere I40.0 Infective myocarditis 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 I42.9 Cardiomyopathy, unspecified I43 Cardiomyopathy in diseases classified elsewhere I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.91 Unspecified atrial fibrillation I48.92 Unspecified 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 I60.00 Nontraumatic subarachnoid hemorrhage from unspecified carotid siphon and bifurcation I60.01 Nontraumatic subarachnoid hemorrhage from right carotid siphon and bifurcation I60.02 Nontraumatic subarachnoid hemorrhage from left carotid siphon and bifurcation I60.10 Nontraumatic subarachnoid hemorrhage from unspecified middle cerebral artery I60.11 Nontraumatic subarachnoid hemorrhage from right middle cerebral artery I60.12 Nontraumatic subarachnoid hemorrhage from left middle cerebral artery Printed on 10/27/2018.

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ICD-10 Codes Description I60.30 Nontraumatic subarachnoid hemorrhage from unspecified posterior communicating artery I60.31 Nontraumatic subarachnoid hemorrhage from right posterior communicating artery I60.32 Nontraumatic subarachnoid hemorrhage from left posterior communicating artery I60.4 Nontraumatic subarachnoid hemorrhage from basilar artery I60.50 Nontraumatic subarachnoid hemorrhage from unspecified vertebral artery I60.51 Nontraumatic subarachnoid hemorrhage from right vertebral artery I60.52 Nontraumatic subarachnoid hemorrhage from left vertebral artery I60.6 Nontraumatic subarachnoid hemorrhage from other intracranial arteries I60.7 Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery I60.8 Other nontraumatic subarachnoid hemorrhage I60.9 Nontraumatic subarachnoid hemorrhage, unspecified I62.9 Nontraumatic intracranial hemorrhage, unspecified I63.013 Cerebral infarction due to thrombosis of bilateral vertebral arteries I63.033 Cerebral infarction due to thrombosis of bilateral carotid arteries I63.113 Cerebral infarction due to embolism of bilateral vertebral arteries I63.133 Cerebral infarction due to embolism of bilateral carotid arteries I63.213 Cerebral infarction due to unspecified occlusion or stenosis of bilateral vertebral arteries I63.233 Cerebral infarction due to unspecified occlusion or stenosis of bilateral carotid arteries I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery I63.311 Cerebral infarction due to thrombosis of right middle cerebral artery I63.312 Cerebral infarction due to thrombosis of left middle cerebral artery I63.313 Cerebral infarction due to thrombosis of bilateral middle cerebral arteries I63.319 Cerebral infarction due to thrombosis of unspecified middle cerebral artery I63.321 Cerebral infarction due to thrombosis of right anterior cerebral artery I63.322 Cerebral infarction due to thrombosis of left anterior cerebral artery I63.323 Cerebral infarction due to thrombosis of bilateral anterior cerebral arteries I63.329 Cerebral infarction due to thrombosis of unspecified anterior cerebral artery I63.331 Cerebral infarction due to thrombosis of right posterior cerebral artery I63.332 Cerebral infarction due to thrombosis of left posterior cerebral artery I63.333 Cerebral infarction due to thrombosis of bilateral posterior cerebral arteries I63.339 Cerebral infarction due to thrombosis of unspecified posterior cerebral artery I63.341 Cerebral infarction due to thrombosis of right cerebellar artery I63.342 Cerebral infarction due to thrombosis of left cerebellar artery I63.343 Cerebral infarction due to thrombosis of bilateral cerebellar arteries I63.349 Cerebral infarction due to thrombosis of unspecified cerebellar artery I63.39 Cerebral infarction due to thrombosis of other cerebral artery I63.40 Cerebral infarction due to embolism of unspecified cerebral artery 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 I63.419 Cerebral infarction due to embolism of unspecified middle cerebral artery 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 I63.429 Cerebral infarction due to embolism of unspecified anterior cerebral artery 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 I63.439 Cerebral infarction due to embolism of unspecified posterior cerebral artery 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 I63.449 Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other cerebral artery I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I63.511 Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I63.513 Cerebral infarction due to unspecified occlusion or stenosis of bilateral middle cerebral arteries Printed on 10/27/2018.

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ICD-10 Codes Description I63.519 Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery I63.521 Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery I63.522 Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery I63.523 Cerebral infarction due to unspecified occlusion or stenosis of bilateral anterior cerebral arteries I63.529 Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior cerebral artery I63.531 Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery I63.532 Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery I63.533 Cerebral infarction due to unspecified occlusion or stenosis of bilateral posterior cerebral arteries I63.539 Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior cerebral artery I63.541 Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I63.542 Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery I63.543 Cerebral infarction due to unspecified occlusion or stenosis of bilateral cerebellar arteries I63.549 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I63.81 Other cerebral infarction due to occlusion or stenosis of small artery I63.89 Other cerebral infarction I63.9 Cerebral infarction, unspecified 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 I66.09 Occlusion and stenosis of unspecified middle cerebral artery 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 I66.19 Occlusion and stenosis of unspecified anterior cerebral artery 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 I66.29 Occlusion and stenosis of unspecified posterior cerebral artery I66.3 Occlusion and stenosis of cerebellar arteries I66.9 Occlusion and stenosis of unspecified cerebral artery I67.841 Reversible cerebrovascular vasoconstriction syndrome I67.848 Other cerebrovascular vasospasm and vasoconstriction I67.89 Other cerebrovascular disease I70.0 Atherosclerosis of aorta I71.00 Dissection of unspecified site of aorta I71.01 Dissection of thoracic aorta I71.03 Dissection of thoracoabdominal aorta I71.1 Thoracic aortic aneurysm, ruptured I71.2 Thoracic aortic aneurysm, without rupture I71.5 Thoracoabdominal aortic aneurysm, ruptured I71.6 Thoracoabdominal aortic aneurysm, without rupture I74.11 Embolism and thrombosis of thoracic aorta I74.2 Embolism and thrombosis of arteries of the upper extremities I74.3 Embolism and thrombosis of arteries of the lower extremities I74.4 Embolism and thrombosis of arteries of extremities, unspecified I74.5 Embolism and thrombosis of iliac artery I74.8 Embolism and thrombosis of other arteries I74.9 Embolism and thrombosis of unspecified artery I75.89 Atheroembolism of other site I76 Septic arterial embolism I77.2 Rupture of artery I82.220 Acute embolism and thrombosis of inferior vena cava Printed on 10/27/2018.

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ICD-10 Codes Description I82.221 Chronic embolism and thrombosis of inferior vena cava I87.1 Compression of vein 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 K68.11 Postprocedural retroperitoneal abscess M32.11 Endocarditis in systemic lupus erythematosus O90.3 Peripartum cardiomyopathy Q21.1 Atrial septal defect R57.0 Cardiogenic shock R57.1 Hypovolemic shock R57.8 Other shock R57.9 Shock, unspecified R65.20 Severe sepsis without septic shock R65.21 Severe sepsis with septic shock R78.81 Bacteremia R93.1* Abnormal findings on diagnostic imaging of heart and coronary circulation R93.89* Abnormal findings on diagnostic imaging of other specified body structures S25.00XA Unspecified injury of thoracic aorta, initial encounter S25.00XD Unspecified injury of thoracic aorta, subsequent encounter S25.00XS Unspecified injury of thoracic aorta, sequela S25.01XA Minor laceration of thoracic aorta, initial encounter S25.01XD Minor laceration of thoracic aorta, subsequent encounter S25.01XS Minor laceration of thoracic aorta, sequela S25.02XA Major laceration of thoracic aorta, initial encounter S25.02XD Major laceration of thoracic aorta, subsequent encounter S25.02XS Major laceration of thoracic aorta, sequela S25.09XA Other specified injury of thoracic aorta, initial encounter S25.09XD Other specified injury of thoracic aorta, subsequent encounter S25.09XS Other specified injury of thoracic aorta, sequela S25.20XA Unspecified injury of superior vena cava, initial encounter S25.20XD Unspecified injury of superior vena cava, subsequent encounter S25.20XS Unspecified injury of superior vena cava, sequela S25.21XA Minor laceration of superior vena cava, initial encounter S25.21XD Minor laceration of superior vena cava, subsequent encounter S25.21XS Minor laceration of superior vena cava, sequela S25.22XA Major laceration of superior vena cava, initial encounter S25.22XD Major laceration of superior vena cava, subsequent encounter S25.22XS Major laceration of superior vena cava, sequela S25.29XA Other specified injury of superior vena cava, initial encounter S25.29XD Other specified injury of superior vena cava, subsequent encounter S25.29XS Other specified injury of superior vena cava, sequela S25.401A Unspecified injury of right pulmonary blood vessels, initial encounter S25.401D Unspecified injury of right pulmonary blood vessels, subsequent encounter S25.401S Unspecified injury of right pulmonary blood vessels, sequela S25.402A Unspecified injury of left pulmonary blood vessels, initial encounter S25.402D Unspecified injury of left pulmonary blood vessels, subsequent encounter S25.402S Unspecified injury of left pulmonary blood vessels, sequela S25.409A Unspecified injury of unspecified pulmonary blood vessels, initial encounter S25.409D Unspecified injury of unspecified pulmonary blood vessels, subsequent encounter Printed on 10/27/2018.

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ICD-10 Codes Description S25.409S Unspecified injury of unspecified pulmonary blood vessels, sequela S25.411A Minor laceration of right pulmonary blood vessels, initial encounter S25.411D Minor laceration of right pulmonary blood vessels, subsequent encounter S25.411S Minor laceration of right pulmonary blood vessels, sequela S25.412A Minor laceration of left pulmonary blood vessels, initial encounter S25.412D Minor laceration of left pulmonary blood vessels, subsequent encounter S25.412S Minor laceration of left pulmonary blood vessels, sequela S25.419A Minor laceration of unspecified pulmonary blood vessels, initial encounter S25.419D Minor laceration of unspecified pulmonary blood vessels, subsequent encounter S25.419S Minor laceration of unspecified pulmonary blood vessels, sequela S25.421A Major laceration of right pulmonary blood vessels, initial encounter S25.421D Major laceration of right pulmonary blood vessels, subsequent encounter S25.421S Major laceration of right pulmonary blood vessels, sequela S25.422A Major laceration of left pulmonary blood vessels, initial encounter S25.422D Major laceration of left pulmonary blood vessels, subsequent encounter S25.422S Major laceration of left pulmonary blood vessels, sequela S25.429A Major laceration of unspecified pulmonary blood vessels, initial encounter S25.429D Major laceration of unspecified pulmonary blood vessels, subsequent encounter S25.429S Major laceration of unspecified pulmonary blood vessels, sequela S25.491A Other specified injury of right pulmonary blood vessels, initial encounter S25.491D Other specified injury of right pulmonary blood vessels, subsequent encounter S25.491S Other specified injury of right pulmonary blood vessels, sequela S25.492A Other specified injury of left pulmonary blood vessels, initial encounter S25.492D Other specified injury of left pulmonary blood vessels, subsequent encounter S25.492S Other specified injury of left pulmonary blood vessels, sequela S25.499A Other specified injury of unspecified pulmonary blood vessels, initial encounter S25.499D Other specified injury of unspecified pulmonary blood vessels, subsequent encounter S25.499S Other specified injury of unspecified pulmonary blood vessels, sequela S25.90XA Unspecified injury of unspecified blood vessel of thorax, initial encounter S25.90XD Unspecified injury of unspecified blood vessel of thorax, subsequent encounter S25.90XS Unspecified injury of unspecified blood vessel of thorax, sequela S25.91XA Laceration of unspecified blood vessel of thorax, initial encounter S25.91XD Laceration of unspecified blood vessel of thorax, subsequent encounter S25.91XS Laceration of unspecified blood vessel of thorax, sequela S25.99XA Other specified injury of unspecified blood vessel of thorax, initial encounter S25.99XD Other specified injury of unspecified blood vessel of thorax, subsequent encounter S25.99XS Other specified injury of unspecified blood vessel of thorax, sequela S26.00XA Unspecified injury of heart with hemopericardium, initial encounter S26.00XD Unspecified injury of heart with hemopericardium, subsequent encounter S26.00XS Unspecified injury of heart with hemopericardium, sequela S26.01XA Contusion of heart with hemopericardium, initial encounter S26.01XD Contusion of heart with hemopericardium, subsequent encounter S26.01XS Contusion of heart with hemopericardium, sequela S26.020A Mild laceration of heart with hemopericardium, initial encounter S26.020D Mild laceration of heart with hemopericardium, subsequent encounter S26.020S Mild laceration of heart with hemopericardium, sequela S26.021A Moderate laceration of heart with hemopericardium, initial encounter S26.021D Moderate laceration of heart with hemopericardium, subsequent encounter S26.021S Moderate laceration of heart with hemopericardium, sequela S26.022A Major laceration of heart with hemopericardium, initial encounter S26.022D Major laceration of heart with hemopericardium, subsequent encounter S26.022S Major laceration of heart with hemopericardium, sequela S26.09XA Other injury of heart with hemopericardium, initial encounter S26.09XD Other injury of heart with hemopericardium, subsequent encounter S26.09XS Other injury of heart with hemopericardium, sequela S26.10XA Unspecified injury of heart without hemopericardium, initial encounter S26.10XD Unspecified injury of heart without hemopericardium, subsequent encounter S26.10XS Unspecified injury of heart without hemopericardium, sequela Printed on 10/27/2018.

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ICD-10 Codes Description S26.11XA Contusion of heart without hemopericardium, initial encounter S26.11XD Contusion of heart without hemopericardium, subsequent encounter S26.11XS Contusion of heart without hemopericardium, sequela S26.12XA Laceration of heart without hemopericardium, initial encounter S26.12XD Laceration of heart without hemopericardium, subsequent encounter S26.12XS Laceration of heart without hemopericardium, sequela S26.19XA Other injury of heart without hemopericardium, initial encounter S26.19XD Other injury of heart without hemopericardium, subsequent encounter S26.19XS Other injury of heart without hemopericardium, sequela S26.90XA Unspecified injury of heart, unspecified with or without hemopericardium, initial encounter S26.90XD Unspecified injury of heart, unspecified with or without hemopericardium, subsequent encounter S26.90XS Unspecified injury of heart, unspecified with or without hemopericardium, sequela S26.91XA Contusion of heart, unspecified with or without hemopericardium, initial encounter S26.91XD Contusion of heart, unspecified with or without hemopericardium, subsequent encounter S26.91XS Contusion of heart, unspecified with or without hemopericardium, sequela S26.92XA Laceration of heart, unspecified with or without hemopericardium, initial encounter S26.92XD Laceration of heart, unspecified with or without hemopericardium, subsequent encounter S26.92XS Laceration of heart, unspecified with or without hemopericardium, sequela S26.99XA Other injury of heart, unspecified with or without hemopericardium, initial encounter S26.99XD Other injury of heart, unspecified with or without hemopericardium, subsequent encounter S26.99XS Other injury of heart, unspecified with or without hemopericardium, sequela T79.4XXA Traumatic shock, initial encounter T79.4XXD Traumatic shock, subsequent encounter T79.4XXS Traumatic shock, sequela T80.0XXA Air embolism following infusion, transfusion and therapeutic injection, initial encounter T80.0XXD Air embolism following infusion, transfusion and therapeutic injection, subsequent encounter T80.0XXS Air embolism following infusion, transfusion and therapeutic injection, sequela T81.10XA Postprocedural shock unspecified, initial encounter T81.10XD Postprocedural shock unspecified, subsequent encounter T81.10XS Postprocedural shock unspecified, sequela T81.11XA Postprocedural cardiogenic shock, initial encounter T81.11XD Postprocedural cardiogenic shock, subsequent encounter T81.11XS Postprocedural cardiogenic shock, sequela T81.12XA Postprocedural septic shock, initial encounter T81.12XD Postprocedural septic shock, subsequent encounter T81.12XS Postprocedural septic shock, sequela T81.19XA Other postprocedural shock, initial encounter T81.19XD Other postprocedural shock, subsequent encounter T81.19XS Other postprocedural shock, sequela T81.44XA Sepsis following a procedure, initial encounter T81.44XD Sepsis following a procedure, subsequent encounter T81.44XS Sepsis following a procedure, sequela T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter T82.01XD Breakdown (mechanical) of heart valve prosthesis, subsequent encounter T82.01XS Breakdown (mechanical) of heart valve prosthesis, sequela T82.02XA Displacement of heart valve prosthesis, initial encounter T82.02XD Displacement of heart valve prosthesis, subsequent encounter T82.02XS Displacement of heart valve prosthesis, sequela T82.03XA Leakage of heart valve prosthesis, initial encounter T82.03XD Leakage of heart valve prosthesis, subsequent encounter T82.03XS Leakage of heart valve prosthesis, sequela T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter T82.09XD Other mechanical complication of heart valve prosthesis, subsequent encounter T82.09XS Other mechanical complication of heart valve prosthesis, sequela T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter T82.110S Breakdown (mechanical) of cardiac electrode, sequela T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter Printed on 10/27/2018.

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ICD-10 Codes Description T82.111D Breakdown (mechanical) of cardiac pulse generator (battery), subsequent encounter T82.111S Breakdown (mechanical) of cardiac pulse generator (battery), sequela T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter T82.118D Breakdown (mechanical) of other cardiac electronic device, subsequent encounter T82.118S Breakdown (mechanical) of other cardiac electronic device, sequela T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter T82.119D Breakdown (mechanical) of unspecified cardiac electronic device, subsequent encounter T82.119S Breakdown (mechanical) of unspecified cardiac electronic device, sequela T82.120A Displacement of cardiac electrode, initial encounter T82.120D Displacement of cardiac electrode, subsequent encounter T82.120S Displacement of cardiac electrode, sequela T82.121A Displacement of cardiac pulse generator (battery), initial encounter T82.121D Displacement of cardiac pulse generator (battery), subsequent encounter T82.121S Displacement of cardiac pulse generator (battery), sequela T82.128A Displacement of other cardiac electronic device, initial encounter T82.128D Displacement of other cardiac electronic device, subsequent encounter T82.128S Displacement of other cardiac electronic device, sequela T82.129A Displacement of unspecified cardiac electronic device, initial encounter T82.129D Displacement of unspecified cardiac electronic device, subsequent encounter T82.129S Displacement of unspecified cardiac electronic device, sequela T82.190A Other mechanical complication of cardiac electrode, initial encounter T82.190D Other mechanical complication of cardiac electrode, subsequent encounter T82.190S Other mechanical complication of cardiac electrode, sequela T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter T82.191D Other mechanical complication of cardiac pulse generator (battery), subsequent encounter T82.191S Other mechanical complication of cardiac pulse generator (battery), sequela T82.198A Other mechanical complication of other cardiac electronic device, initial encounter T82.198D Other mechanical complication of other cardiac electronic device, subsequent encounter T82.198S Other mechanical complication of other cardiac electronic device, sequela T82.199A Other mechanical complication of unspecified cardiac device, initial encounter T82.199D Other mechanical complication of unspecified cardiac device, subsequent encounter T82.199S Other mechanical complication of unspecified cardiac device, sequela T82.310A Breakdown (mechanical) of aortic (bifurcation) graft (replacement), initial encounter T82.310D Breakdown (mechanical) of aortic (bifurcation) graft (replacement), subsequent encounter T82.310S Breakdown (mechanical) of aortic (bifurcation) graft (replacement), sequela T82.311A Breakdown (mechanical) of carotid arterial graft (bypass), initial encounter T82.311D Breakdown (mechanical) of carotid arterial graft (bypass), subsequent encounter T82.311S Breakdown (mechanical) of carotid arterial graft (bypass), sequela T82.312A Breakdown (mechanical) of femoral arterial graft (bypass), initial encounter T82.312D Breakdown (mechanical) of femoral arterial graft (bypass), subsequent encounter T82.312S Breakdown (mechanical) of femoral arterial graft (bypass), sequela T82.318A Breakdown (mechanical) of other vascular grafts, initial encounter T82.318D Breakdown (mechanical) of other vascular grafts, subsequent encounter T82.318S Breakdown (mechanical) of other vascular grafts, sequela T82.319A Breakdown (mechanical) of unspecified vascular grafts, initial encounter T82.319D Breakdown (mechanical) of unspecified vascular grafts, subsequent encounter T82.319S Breakdown (mechanical) of unspecified vascular grafts, sequela T82.320A Displacement of aortic (bifurcation) graft (replacement), initial encounter T82.320D Displacement of aortic (bifurcation) graft (replacement), subsequent encounter T82.320S Displacement of aortic (bifurcation) graft (replacement), sequela T82.321A Displacement of carotid arterial graft (bypass), initial encounter T82.321D Displacement of carotid arterial graft (bypass), subsequent encounter T82.321S Displacement of carotid arterial graft (bypass), sequela T82.322A Displacement of femoral arterial graft (bypass), initial encounter T82.322D Displacement of femoral arterial graft (bypass), subsequent encounter T82.322S Displacement of femoral arterial graft (bypass), sequela T82.328A Displacement of other vascular grafts, initial encounter T82.328D Displacement of other vascular grafts, subsequent encounter Printed on 10/27/2018.

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ICD-10 Codes Description T82.328S Displacement of other vascular grafts, sequela T82.329A Displacement of unspecified vascular grafts, initial encounter T82.329D Displacement of unspecified vascular grafts, subsequent encounter T82.329S Displacement of unspecified vascular grafts, sequela T82.330A Leakage of aortic (bifurcation) graft (replacement), initial encounter T82.330D Leakage of aortic (bifurcation) graft (replacement), subsequent encounter T82.330S Leakage of aortic (bifurcation) graft (replacement), sequela T82.331A Leakage of carotid arterial graft (bypass), initial encounter T82.331D Leakage of carotid arterial graft (bypass), subsequent encounter T82.331S Leakage of carotid arterial graft (bypass), sequela T82.332A Leakage of femoral arterial graft (bypass), initial encounter T82.332D Leakage of femoral arterial graft (bypass), subsequent encounter T82.332S Leakage of femoral arterial graft (bypass), sequela T82.338A Leakage of other vascular grafts, initial encounter T82.338D Leakage of other vascular grafts, subsequent encounter T82.338S Leakage of other vascular grafts, sequela T82.339A Leakage of unspecified vascular graft, initial encounter T82.339D Leakage of unspecified vascular graft, subsequent encounter T82.339S Leakage of unspecified vascular graft, sequela T82.390A Other mechanical complication of aortic (bifurcation) graft (replacement), initial encounter T82.390D Other mechanical complication of aortic (bifurcation) graft (replacement), subsequent encounter T82.390S Other mechanical complication of aortic (bifurcation) graft (replacement), sequela T82.391A Other mechanical complication of carotid arterial graft (bypass), initial encounter T82.391D Other mechanical complication of carotid arterial graft (bypass), subsequent encounter T82.391S Other mechanical complication of carotid arterial graft (bypass), sequela T82.392A Other mechanical complication of femoral arterial graft (bypass), initial encounter T82.392D Other mechanical complication of femoral arterial graft (bypass), subsequent encounter T82.392S Other mechanical complication of femoral arterial graft (bypass), sequela T82.398A Other mechanical complication of other vascular grafts, initial encounter T82.398D Other mechanical complication of other vascular grafts, subsequent encounter T82.398S Other mechanical complication of other vascular grafts, sequela T82.399A Other mechanical complication of unspecified vascular grafts, initial encounter T82.399D Other mechanical complication of unspecified vascular grafts, subsequent encounter T82.399S Other mechanical complication of unspecified vascular grafts, sequela T82.41XA Breakdown (mechanical) of vascular dialysis catheter, initial encounter T82.41XD Breakdown (mechanical) of vascular dialysis catheter, subsequent encounter T82.41XS Breakdown (mechanical) of vascular dialysis catheter, sequela T82.42XA Displacement of vascular dialysis catheter, initial encounter T82.42XD Displacement of vascular dialysis catheter, subsequent encounter T82.42XS Displacement of vascular dialysis catheter, sequela T82.43XA Leakage of vascular dialysis catheter, initial encounter T82.43XD Leakage of vascular dialysis catheter, subsequent encounter T82.43XS Leakage of vascular dialysis catheter, sequela T82.49XA Other complication of vascular dialysis catheter, initial encounter T82.49XD Other complication of vascular dialysis catheter, subsequent encounter T82.49XS Other complication of vascular dialysis catheter, sequela T82.510A Breakdown (mechanical) of surgically created arteriovenous fistula, initial encounter T82.510D Breakdown (mechanical) of surgically created arteriovenous fistula, subsequent encounter T82.510S Breakdown (mechanical) of surgically created arteriovenous fistula, sequela T82.511A Breakdown (mechanical) of surgically created arteriovenous shunt, initial encounter T82.511D Breakdown (mechanical) of surgically created arteriovenous shunt, subsequent encounter T82.511S Breakdown (mechanical) of surgically created arteriovenous shunt, sequela T82.513A Breakdown (mechanical) of balloon (counterpulsation) device, initial encounter T82.513D Breakdown (mechanical) of balloon (counterpulsation) device, subsequent encounter T82.513S Breakdown (mechanical) of balloon (counterpulsation) device, sequela T82.514A Breakdown (mechanical) of infusion catheter, initial encounter T82.514D Breakdown (mechanical) of infusion catheter, subsequent encounter T82.514S Breakdown (mechanical) of infusion catheter, sequela Printed on 10/27/2018.

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ICD-10 Codes Description T82.515A Breakdown (mechanical) of umbrella device, initial encounter T82.515D Breakdown (mechanical) of umbrella device, subsequent encounter T82.515S Breakdown (mechanical) of umbrella device, sequela T82.518A Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter T82.518D Breakdown (mechanical) of other cardiac and vascular devices and implants, subsequent encounter T82.518S Breakdown (mechanical) of other cardiac and vascular devices and implants, sequela T82.519A Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, initial encounter T82.519D Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, subsequent encounter T82.519S Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, sequela T82.520A Displacement of surgically created arteriovenous fistula, initial encounter T82.520D Displacement of surgically created arteriovenous fistula, subsequent encounter T82.520S Displacement of surgically created arteriovenous fistula, sequela T82.521A Displacement of surgically created arteriovenous shunt, initial encounter T82.521D Displacement of surgically created arteriovenous shunt, subsequent encounter T82.521S Displacement of surgically created arteriovenous shunt, sequela T82.523A Displacement of balloon (counterpulsation) device, initial encounter T82.523D Displacement of balloon (counterpulsation) device, subsequent encounter T82.523S Displacement of balloon (counterpulsation) device, sequela T82.524A Displacement of infusion catheter, initial encounter T82.524D Displacement of infusion catheter, subsequent encounter T82.524S Displacement of infusion catheter, sequela T82.525A Displacement of umbrella device, initial encounter T82.525D Displacement of umbrella device, subsequent encounter T82.525S Displacement of umbrella device, sequela T82.528A Displacement of other cardiac and vascular devices and implants, initial encounter T82.528D Displacement of other cardiac and vascular devices and implants, subsequent encounter T82.528S Displacement of other cardiac and vascular devices and implants, sequela T82.529A Displacement of unspecified cardiac and vascular devices and implants, initial encounter T82.529D Displacement of unspecified cardiac and vascular devices and implants, subsequent encounter T82.529S Displacement of unspecified cardiac and vascular devices and implants, sequela T82.530A Leakage of surgically created arteriovenous fistula, initial encounter T82.530D Leakage of surgically created arteriovenous fistula, subsequent encounter T82.530S Leakage of surgically created arteriovenous fistula, sequela T82.531A Leakage of surgically created arteriovenous shunt, initial encounter T82.531D Leakage of surgically created arteriovenous shunt, subsequent encounter T82.531S Leakage of surgically created arteriovenous shunt, sequela T82.533A Leakage of balloon (counterpulsation) device, initial encounter T82.533D Leakage of balloon (counterpulsation) device, subsequent encounter T82.533S Leakage of balloon (counterpulsation) device, sequela T82.534A Leakage of infusion catheter, initial encounter T82.534D Leakage of infusion catheter, subsequent encounter T82.534S Leakage of infusion catheter, sequela T82.535A Leakage of umbrella device, initial encounter T82.535D Leakage of umbrella device, subsequent encounter T82.535S Leakage of umbrella device, sequela T82.538A Leakage of other cardiac and vascular devices and implants, initial encounter T82.538D Leakage of other cardiac and vascular devices and implants, subsequent encounter T82.538S Leakage of other cardiac and vascular devices and implants, sequela T82.539A Leakage of unspecified cardiac and vascular devices and implants, initial encounter T82.539D Leakage of unspecified cardiac and vascular devices and implants, subsequent encounter T82.539S Leakage of unspecified cardiac and vascular devices and implants, sequela T82.590A Other mechanical complication of surgically created arteriovenous fistula, initial encounter T82.590D Other mechanical complication of surgically created arteriovenous fistula, subsequent encounter T82.590S Other mechanical complication of surgically created arteriovenous fistula, sequela T82.591A Other mechanical complication of surgically created arteriovenous shunt, initial encounter Printed on 10/27/2018.

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ICD-10 Codes Description T82.591D Other mechanical complication of surgically created arteriovenous shunt, subsequent encounter T82.591S Other mechanical complication of surgically created arteriovenous shunt, sequela T82.593A Other mechanical complication of balloon (counterpulsation) device, initial encounter T82.593D Other mechanical complication of balloon (counterpulsation) device, subsequent encounter T82.593S Other mechanical complication of balloon (counterpulsation) device, sequela T82.594A Other mechanical complication of infusion catheter, initial encounter T82.594D Other mechanical complication of infusion catheter, subsequent encounter T82.594S Other mechanical complication of infusion catheter, sequela T82.595A Other mechanical complication of umbrella device, initial encounter T82.595D Other mechanical complication of umbrella device, subsequent encounter T82.595S Other mechanical complication of umbrella device, sequela T82.598A Other mechanical complication of other cardiac and vascular devices and implants, initial encounter T82.598D Other mechanical complication of other cardiac and vascular devices and implants, subsequent encounter T82.598S Other mechanical complication of other cardiac and vascular devices and implants, sequela T82.599A Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter T82.599D Other mechanical complication of unspecified cardiac and vascular devices and implants, subsequent encounter T82.599S Other mechanical complication of unspecified cardiac and vascular devices and implants, sequela T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter T82.6XXD Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter T82.6XXS Infection and inflammatory reaction due to cardiac valve prosthesis, sequela T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter T82.7XXD Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter T82.7XXS Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter T82.817D Embolism due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.817S Embolism due to cardiac prosthetic devices, implants and grafts, sequela T82.827A Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter T82.827D Fibrosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.827S Fibrosis due to cardiac prosthetic devices, implants and grafts, sequela T82.837A Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter T82.837D Hemorrhage due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.837S Hemorrhage due to cardiac prosthetic devices, implants and grafts, sequela T82.847A Pain due to cardiac prosthetic devices, implants and grafts, initial encounter T82.847D Pain due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.847S Pain due to cardiac prosthetic devices, implants and grafts, sequela T82.855A - T82.855S Stenosis of coronary artery stent, initial encounter - Stenosis of coronary artery stent, sequela T82.856A Stenosis of peripheral vascular stent, initial encounter T82.857A Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter T82.857D Stenosis of other cardiac prosthetic devices, implants and grafts, subsequent encounter T82.857S Stenosis of other cardiac prosthetic devices, implants and grafts, sequela T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter T82.867D Thrombosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter T82.897D Other specified complication of cardiac prosthetic devices, implants and grafts, subsequent encounter T82.897S Other specified complication of cardiac prosthetic devices, implants and grafts, sequela T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter Printed on 10/27/2018.

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ICD-10 Codes Description T82.9XXD Unspecified complication of cardiac and vascular prosthetic device, implant and graft, subsequent encounter T82.9XXS Unspecified complication of cardiac and vascular prosthetic device, implant and graft, sequela T84.50XA Infection and inflammatory reaction due to unspecified internal joint prosthesis, initial encounter T84.50XD Infection and inflammatory reaction due to unspecified internal joint prosthesis, subsequent encounter T84.50XS Infection and inflammatory reaction due to unspecified internal joint prosthesis, sequela T84.51XA Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter T84.51XD Infection and inflammatory reaction due to internal right hip prosthesis, subsequent encounter T84.51XS Infection and inflammatory reaction due to internal right hip prosthesis, sequela T84.52XA Infection and inflammatory reaction due to internal left hip prosthesis, initial encounter T84.52XD Infection and inflammatory reaction due to internal left hip prosthesis, subsequent encounter T84.52XS Infection and inflammatory reaction due to internal left hip prosthesis, sequela T84.53XA Infection and inflammatory reaction due to internal right knee prosthesis, initial encounter T84.53XD Infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter T84.53XS Infection and inflammatory reaction due to internal right knee prosthesis, sequela T84.54XA Infection and inflammatory reaction due to internal left knee prosthesis, initial encounter T84.54XD Infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter T84.54XS Infection and inflammatory reaction due to internal left knee prosthesis, sequela T84.59XA Infection and inflammatory reaction due to other internal joint prosthesis, initial encounter T84.59XD Infection and inflammatory reaction due to other internal joint prosthesis, subsequent encounter T84.59XS Infection and inflammatory reaction due to other internal joint prosthesis, sequela T85.79XA Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter T85.79XD Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, subsequent encounter Z01.30* Encounter for examination of blood pressure without abnormal findings Z01.31* Encounter for examination of blood pressure with abnormal findings 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 Z94.1 Heart transplant status Z94.2 Lung transplant status Z94.3 Heart and lungs transplant status Z95.2 Presence of prosthetic heart valve Z98.890 Other specified postprocedural states Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation: * Use ICD-10 codes R93.1 or R93.89 when a TEE is performed because of inadequate visualization of cardiac anatomy on TTE, for structures normally visualized by TTE and for which TEE is not usually indicated.

The ICD-10 codes R93.1 or R93.89 should be coded as the primary diagnosis and the cardiac abnormality should be coded as a secondary diagnosis.

* Use ICD-10 codes Z01.30, Z01.31, or Z01.89 when a TEE is performed during an open chest procedure. ICD-10 codes Z01.30, Z01.31, or Z01.89 should be coded as the primary diagnosis and the reason for the surgical procedure should be coded as the secondary diagnosis. Group 2 Paragraph: The following diagnoses are covered for CPT codes 93315, 93316, 93317 and C8926. (When reporting add-on CPT codes 93320, 93321 and 93325, the same ICD-10-CM code should be used as that used for the base code to which it is attached): Printed on 10/27/2018. Page 21 of 30

ICD-10 Codes Description 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 Q21.1 Atrial septal defect Q21.2 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 Q22.9 Congenital malformation of tricuspid valve, unspecified 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 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 Q25.21 Interruption of aortic arch Q25.29 Other atresia of aorta Q25.3 Supravalvular aortic stenosis Q25.40 - Q25.49 Congenital malformation of aorta unspecified - 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 Q25.9 Congenital malformation of great arteries, unspecified Q26.0 Congenital stenosis of vena cava Q26.1 Persistent left superior vena cava Q26.2 Total anomalous pulmonary venous connection Q26.3 Partial anomalous pulmonary venous connection Q26.4 Anomalous pulmonary venous connection, unspecified Q26.8 Other congenital malformations of great veins Q26.9 Congenital malformation of great vein, unspecified Q87.40 Marfan's syndrome, unspecified Q87.410 Marfan's syndrome with aortic dilation Q87.418 Marfan's syndrome with other cardiovascular manifestations Q87.42 Marfan's syndrome with ocular manifestations Q87.43 Marfan's syndrome with skeletal manifestation Group 2 Codes: Printed on 10/27/2018.

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ICD-10 Codes Description I05.0 Rheumatic mitral stenosis I05.1 Rheumatic mitral insufficiency I05.2 Rheumatic mitral stenosis with insufficiency I05.8 Other rheumatic mitral valve diseases I05.9 Rheumatic mitral valve disease, unspecified I08.0 Rheumatic disorders of both mitral and aortic valves I08.1 Rheumatic disorders of both mitral and tricuspid valves I08.3 Combined rheumatic disorders of mitral, aortic and tricuspid valves I08.8 Other rheumatic multiple valve diseases I08.9 Rheumatic multiple valve disease, unspecified 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 I33.0 Acute and subacute infective endocarditis I34.0 Nonrheumatic mitral (valve) insufficiency I34.1 Nonrheumatic mitral (valve) prolapse I34.8 Other nonrheumatic mitral valve disorders I34.9 Nonrheumatic mitral valve disorder, unspecified I36.1 Nonrheumatic tricuspid (valve) insufficiency I36.2 Nonrheumatic tricuspid (valve) stenosis with insufficiency I36.8 Other nonrheumatic tricuspid valve disorders I36.9 Nonrheumatic tricuspid valve disorder, unspecified I39 Endocarditis and heart valve disorders in diseases classified elsewhere I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation I48.3 Typical atrial flutter I48.4 Atypical atrial flutter I48.91 Unspecified atrial fibrillation I48.92 Unspecified 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 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 Q21.1 Atrial septal defect Q21.2 Atrioventricular septal defect Q23.2 Congenital mitral stenosis Q23.3 Congenital mitral insufficiency Q23.4 Hypoplastic left heart syndrome T82.01XA Breakdown (mechanical) of heart valve prosthesis, initial encounter T82.01XD Breakdown (mechanical) of heart valve prosthesis, subsequent encounter Group 3 Paragraph: The following diagnoses are covered for CPT codes 76376 and 76377 when performed for 3-D imaging with CPT codes 93312, 93314, C8925, 93315, 93317 or C8926: Group 3 Codes: Printed on 10/27/2018.

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ICD-10 Codes Description T82.01XS Breakdown (mechanical) of heart valve prosthesis, sequela T82.02XA Displacement of heart valve prosthesis, initial encounter T82.02XD Displacement of heart valve prosthesis, subsequent encounter T82.02XS Displacement of heart valve prosthesis, sequela T82.03XA Leakage of heart valve prosthesis, initial encounter T82.03XD Leakage of heart valve prosthesis, subsequent encounter T82.03XS Leakage of heart valve prosthesis, sequela T82.09XA Other mechanical complication of heart valve prosthesis, initial encounter T82.09XD Other mechanical complication of heart valve prosthesis, subsequent encounter T82.09XS Other mechanical complication of heart valve prosthesis, sequela T82.519A Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, initial encounter T82.519D Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, subsequent encounter T82.519S Breakdown (mechanical) of unspecified cardiac and vascular devices and implants, sequela T82.529A Displacement of unspecified cardiac and vascular devices and implants, initial encounter T82.529D Displacement of unspecified cardiac and vascular devices and implants, subsequent encounter T82.529S Displacement of unspecified cardiac and vascular devices and implants, sequela T82.539A Leakage of unspecified cardiac and vascular devices and implants, initial encounter T82.539D Leakage of unspecified cardiac and vascular devices and implants, subsequent encounter T82.539S Leakage of unspecified cardiac and vascular devices and implants, sequela T82.599A Other mechanical complication of unspecified cardiac and vascular devices and implants, initial encounter T82.599D Other mechanical complication of unspecified cardiac and vascular devices and implants, subsequent encounter T82.599S Other mechanical complication of unspecified cardiac and vascular devices and implants, sequela T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter T82.6XXD Infection and inflammatory reaction due to cardiac valve prosthesis, subsequent encounter T82.6XXS Infection and inflammatory reaction due to cardiac valve prosthesis, sequela T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter T82.7XXD Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter T82.7XXS Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, sequela T82.817A Embolism due to cardiac prosthetic devices, implants and grafts, initial encounter T82.817D Embolism due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.817S Embolism due to cardiac prosthetic devices, implants and grafts, sequela T82.827A Fibrosis due to cardiac prosthetic devices, implants and grafts, initial encounter T82.827D Fibrosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.827S Fibrosis due to cardiac prosthetic devices, implants and grafts, sequela T82.837A Hemorrhage due to cardiac prosthetic devices, implants and grafts, initial encounter T82.837D Hemorrhage due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.837S Hemorrhage due to cardiac prosthetic devices, implants and grafts, sequela T82.847A Pain due to cardiac prosthetic devices, implants and grafts, initial encounter T82.847D Pain due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.847S Pain due to cardiac prosthetic devices, implants and grafts, sequela T82.857A Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter T82.857D Stenosis of other cardiac prosthetic devices, implants and grafts, subsequent encounter T82.857S Stenosis of other cardiac prosthetic devices, implants and grafts, sequela T82.867A Thrombosis due to cardiac prosthetic devices, implants and grafts, initial encounter T82.867D Thrombosis due to cardiac prosthetic devices, implants and grafts, subsequent encounter T82.867S Thrombosis due to cardiac prosthetic devices, implants and grafts, sequela T82.897A Other specified complication of cardiac prosthetic devices, implants and grafts, initial encounter T82.897D Other specified complication of cardiac prosthetic devices, implants and grafts, subsequent encounter T82.897S Other specified complication of cardiac prosthetic devices, implants and grafts, sequela T82.9XXA Unspecified complication of cardiac and vascular prosthetic device, implant and graft, initial encounter Printed on 10/27/2018.

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ICD-10 Codes Description T82.9XXD Unspecified complication of cardiac and vascular prosthetic device, implant and graft, subsequent encounter T82.9XXS Unspecified complication of cardiac and vascular prosthetic device, implant and graft, sequela 1. TEE services will be covered twice per year for all conditions except endocarditis (ICD-10 code I39), for which four (4) services per year will be covered. 2. TEE may be repeated in patients with repeat episodes of atrial fibrillation/flutter prior to cardioversion. 3. Services exceeding this parameter will be considered not medically necessary, unless there is documentation that the tests were performed for clinical indications reflecting a change in the patient’s status or underlying cardiac condition, or documentation of a new unrelated condition, sign or symptom.

4. In those instances in which repeat tests were denied and a physician has documented a good faith effort to identify them and to request copies of them from previous providers, then NGS could reimburse such tests on appeal.

5. These guidelines do not apply to tests performed on hospital inpatients. ICD-10 Codes that DO NOT Support Medical Necessity N/A ICD-10 Additional Information Back to Top General Information Associated Information Documentation Requirements: A covered service must include a complete interpretation/report by the performing physician, and must be available if requested. The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, as well as reasons for repeat testing.

In those instances in which repeat tests were denied, the physician must document a good faith effort was made to identify them and to request copies of them from previous providers, in order for NGS to consider reimbursement for such tests on appeal. Each service requires a formal written report with interpretation. This report should be kept on file with copies of image documentation (paper or tape) for review if requested. All appropriate measurements should be included in the report. A Doppler interrogation should state the modes used and should give both qualitative and quantitative information.

Documentation of the qualifications of personnel performing tests, as described in the Indications section of the LCD, should be available on request. All documentation must be submitted upon request. Appendices: Not applicable Utilization Guidelines: Sources of Information This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below. Printed on 10/27/2018. Page 25 of 30

ACC/AHA Task Force Report, ACC/AHA Guidelines for the Clinical Application of Echocardiography, JACC.

1990;16(7):1505-28. AdminaStar Federal and other Medicare contractors' policies. AHA Medical/Scientific Statement (Feinberg WM, chair) Guidelines for the management of transient ischemic attacks. From the ad hoc committee on guidelines for the management of transient ischemic attacks of the stroke council of the American Heart Association. Stroke. 1994;25:1320-1335. Ansari A, Transesophageal two-dimensional echocardiography: current perspectives. Prog Cardiovasc Dis. 1993;35(5):349-397.

Besson G, Bogousslavsky J, Hommel M, et al. Patent foramen ovale in young stroke patients with mitral valve prolapse. Acta Neurol Scand. 1994;89:23-26. Biner S, Rafique AM, Kar S, et al. Live three-dimensional transesophageal echocardiography-guided transcatheter closure of a mitral paraprosthetic leak by amplatzer occluder. JASE. 2008;21(11):1282.e7-1282.e9. (published online 15 August 2008). Blanchard D, Kimura BJ, Dittrich HC, DeMaria AN. Transesophageal echocardiography of the aorta. JAMA. 1994;272(7):546-551.

Braunwald E. ed. Heart Disease, A Textbook of Cardiovascular Medicine.

4th ed. WB Saunders, Philadelphia, PA. 1992. Carrier Medical Directors' Cardiology Clinical Workgroup. Cerebral Embolism Task Force. Cardiogenic brain embolism. Arch Neurol. 1986;43:71-84. Cheitlin MD, Alpert JS, Armstrong WF, et al. ACC/AHA Guidelines for the clinical application of echocardiography: executive summary. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography). J Am Coll Cardiol. 1997;29:862-79. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).

2003. http://www.acc.org/clinical/guidelines/echo/index.pdf. Accessed: March 14, 2006.Updated URL: http://www.acc.org/qualityandscience/clinical/guidelines/echo/index.pdf. Accessed: October 27, 2006.

Cigarroa JE, Isselbacher EM, DeSanctis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N Engl J Med. 1993;328(1):35-43. Daniel WG, Mhgge A. Transesophageal echocardiography. N Engl J Med. 1995;332(19):1268-1279. Daniel WG. Transcatheter closure of patent foramen ovale. Therapeutic overkill or elegant management for selected patients at risk? Circulation. 1992;86(6):2013-2015 (editorial.) deBelder MA, Lovat LB, Tourikis L, Leech G, Camm AJ. Limitations of tranosesophageal echocardiography in patients with focal cerebral ischaemic events.

Br Heart J. 1992;67:297-303. deBelder MA, Tourikis L, Leech G, Camm J. Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol. 1992;69:1316-1320.

Demopoulos LA, Tunick PA, Bernstein NE, et al. Protruding atheromas of the aortic arch in symptomatic patients with carotid artery disease. Am Heart J. 1995;129:40-44. DeRook FA, Comess KA, Albers GW, Popp RL. Transesophageal echocardiography in the evaluation of stroke. Ann Intern Med. 1992;117:922-932. Dhandheria B. Transesophageal echocardiography; concise review for primary-care physicians. Mayo Clinic Proc. 1994;69:856-863. Hanna JP, Sun JP, Furlan AJ, et al. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke. 1994;25:782-786.

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Homma S, DiTullio MR, Sacco RL, et al. Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke. 1994;25:582-586. Hung J, Lang R, Flachskampf F, et al. 3D echocardiography: a review of the current status and future directions. J. Am. Soc Echocardiography. 2007;20:213-233. Isselbacher KJ, Braunwa E, Wilson JD, Martin JB, Fauci AS, Kasper DL. Eds. Harrison's Principles of Internal Medicine. 13th ed. McGraw Hill, New York 1994.

Jones EF, Calafiore P, Donnan GA, Tonkin AM. Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly.

Am J Cardiol. 1994;74:596-599. Khoury AF, Afridi I, QuiZones MA, Zoghbi WA. Transesophageal echocardiography in critically ill patients: feasibility, safety, and impact on management. Am Heart J. 1994;127:1363-1371. Kronzon I, Sugeng L, Perk G, et al. Real-time 3D-transesophageal echocardiography in the evaluation of post- operative mitral annuloplasty ring and prosthetic valve dehiscence. Submitted for publication October 2008. Kronzon I, Tunick PA. Transesophageal echocardiography as a tool in the evaluation of patients with embolic disorders. Prog Cardiovasc Dis. 1993;36(1):39-60.

Lindower PD, Gutterman DD. Detection of cardioembolic sources with echocardiography. Comprehensive Therapy 1994. 20(3):174-180. Louie EK, Konstadt SN, Rao TLK, Scanlon PJ. Transesophageal echocardiographic diagnosis of right to left shunting across the foramen ovale in adults without prior stroke. J Am Coll Cardiol. 1993;21:1231-1237. Lucas C, Goullard L, Marchau Jr M, et al. Higher prevalence of atrial septal aneurysms in patient with ischemic stroke of unknown cause. Acta Neurol Scand. 1994;89:210-213.

Mitusch R, Stierle U, Tepe C, et al. Systemic embolism in aortic arch atheromatosis.

Dur Heart J. 1994;15:1373- 1380. Mügge A, Daniel WG, Haverich A, Lichtlen PR. Diagnosis of noninfective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches. Circulation. 1991;83:70-78. Otto, Catherine M. Textbook of clinical echocardiography. 2nd ed., W.B. Saunders Co., 2000. Pearlman AS. Detecting prosthetic valve dysfunction. ACCEL. 1995; 27(10):tape B, side 3 (interview with Holmes, Jr DR.) Pearson AC, Nagelhout D, Castello R, et al. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol.

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Pepi M, Tamborini G, Maltagliati A, et al. Head-to-head comparison of two-and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse, J Am Coll Cardiol. 2006;48:2524-2530. Perk G, Lang RM, Garcia-Fernandez MA, et al. Transcatheter interventions use of real time three dimensional transesophageal echocardiography in intracardiac catheter based interventions. Journal of the American Society of Echocardiography. 2009;22(8). Petty GW, Orencia AJ, Khandheria BK, Whisnant JP. A Population-based study of stroke in the setting of mitral valve prolapse; risk factors and infarct subtype classification.

Mayo Clin Proc. 1994;69:632-634. Sansoy V, Abbott RD, Jayaweera AR, Kaul S. Low yield of transthoracic echocardiography for cardiac source of embolism. Am J Cardiol. 1995;75:166-169.

Stratton JR, Lighty, Jr GW, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional echocardiography: sensitivity, specificity, and causes of uncertainty. Circulation. 1982;66:156-166. Sugeng L, Shernan SK, Salgo IS, et al. Live 3-dimensional transesophageal echocardiography initial experience using the fully-sampled matrix array probe. J Amer Coll Cardiol. 2008;52(6):446-9. Sugeng L, Shernan SK, Weinert L, et al. Real-time 3D transesophageal echocardiography in valve disease: comparison with surgical findings and Evaluation of prosthetic valves. J Am Soc Echocardiography.

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Revision History Date Revision History Number Revision History Explanation Reason(s) for Change 10/01/2018 R9 LCD revised for annual ICD-10 updates to make these changes to Group 1: ICD-10 code I63.8 was deleted and replaced by I63.81 and I63.89. ICD.10 code R93.8 was deleted and replaced by R93.89. ICD-10 codes T81.4XXA, T81.4XXD, and T81.4XXS were deleted and replaced by T81.44XA, T81.44XD and T81.44XS. The descriptors for ICD-10 codes I63.333 and I63.343 were changed. DATE 10/01/2018: At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which require comment and notice.

This revision is not a restriction to the coverage determination; and therefore, not all the fields included are applicable as noted in this policy.

• Revisions Due To ICD-10-CM Code Changes 11/01/2017 R8 2008;21:1347–1354. Wiet SP, Pearce WH, McCarthy WJ, et al. Utility of transesophageal echocardiography in the diagnosis of disease of the thoracic aorta. J Vasc Surg. 1994;20:613-620. Sources reviewed for reconsideration request of July 17, 2017: Hahn RT. State of the art review of echocardiographic imaging in the evaluation and treatment of functional tricuspid regurgitation. Circ Cardiovascular Imaging. 2016;9:1-15. Hahn RT. Transcatheter valve replacement and valve repair: review of procedures and intraprocedural echocardiographic imaging.

Circulation Research. 2016:341-356.

Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Journal of Amer Soc. of Echocardiog. 2013;26:921-964. Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using three- dimensional echocardiography. Journal of Amer Soc. of Echocardiog. 2012;25:3-46. Rodes-Cabau J, Hahn RT, Latib A, et al. Transcatheter therapies for treating tricuspid regurgitation. JACC. 2016;67(15):1829-1845.

Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evalulation of native valvular regurgitation. Journal of Amer Soc. of Echocardiog. 2017;30(4):303-371. Bibliography N/A Back to Top Revision History Information Printed on 10/27/2018. Page 28 of 30

Revision History Date Revision History Number Revision History Explanation Reason(s) for Change LCD revised in response to a reconsideration request to add coverage for tricuspid valve disease.

The Indications section for 3- Dimensional Echocardiography was revised to add Evaluation of tricuspid valve disease and to add codes C8925 and C8926. ICD-10 codes I36.1, I36.2, I36.8 and I36.9 were added to Group 1 (codes 93312, 93313, 93314, and C8925) and Group 3 (CPT codes 76376 and 76377 when performed for 3-D imaging with codes 93312, 93314 or C8925) as payable diagnoses. Code C8925 was added to ICD-10 group 1 and group 3. Code C8926 was added to group 2 and group 3.

Sources reviewed for the reconsideration request were added to the LCD. DATE 11/01/2017: At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which require comment and notice. This revision is not a restriction to the coverage determination; and therefore, not all the fields included are applicable as noted in this policy. • Reconsideration Request 10/01/2017 R7 ICD-10 code descriptions were changed for ICD-10 Codes I63.323,I63.333, I63.513, I63.523, I63.533. DATE 10/01/2017: At this time, the 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which require comment and notice.

This revision is not a restriction to the coverage determination; and therefore, not all the fields included are applicable as noted in this policy.

• Revisions Due To ICD-10-CM Code Changes 04/01/2017 R6 Wording changes have been made throughout for clarity. • Provider Education/Guidance 01/01/2017 R5 The credentialing requirements for physicians performing the interpretation of TEE were revised to add this statement: “or has been credentialed for this procedure by the hospital where the physician performs this service”. ICD-10 codes I08.1, I08.3, I08.9, I34.0, I34.1, I34.8, I34.9, and Q23.4 were added to Group 3, covered ICD-10 codes for CPT codes 76376 and 76377 when performed for 3-D imaging following CPT codes 93312, 93314, 93315 or 93317, effective for dates of service on or after 10/01/2015.

• Provider Education/Guidance • Request for Coverage by a Practitioner (Part B) 10/01/2016 R4 LCD revised for annual ICD-10 update to add multiple ICD-10 codes. • Revisions Due To ICD-10-CM Code Changes 10/01/2015 R3 This statement was omitted from the Group 2 ICD-10 list and has been reinstated: The following diagnoses are covered for CPT codes 93315, 93316, and 93317 (When reporting add-on CPT codes 93320, 93321 and 93325, the same ICD-9-CM code should be used as that used for the base code to which it is attached): • Typographical Error 10/01/2015 R2 ICD-10 codes were revised to add the 7th digit for D=subsequent encounter and S=sequela, where the 7th digit, A=initial encounter was already included.

• Provider Education/Guidance 10/01/2015 R1 LCD updated with changes made since April 2014. • Other Back to Top Associated Documents Attachments N/A Printed on 10/27/2018. Page 29 of 30

Related Local Coverage Documents Article(s) A52868 - Transesophageal Echocardiography (TEE) – Supplemental Instructions Article Related National Coverage Documents N/A Public Version(s) Updated on 09/13/2018 with effective dates 10/01/2018 - N/A Updated on 10/20/2017 with effective dates 11/01/2017 - 09/30/2018 Updated on 10/03/2017 with effective dates 10/01/2017 - 10/31/2017 Some older versions have been archived.

Please visit the MCD Archive Site to retrieve them. Back to Top Keywords N/A Read the LCD Disclaimer Back to Top Printed on 10/27/2018. Page 30 of 30

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