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CodeMap® LCD-L38396


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LCD for Cardiology Non-emergent Outpatient Stress Testing (L38396)
See related Articles:
A56952-Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
A58657-Response to Comments: Cardiology Non-emergent Outpatient Stress Testing

Contractor Information

Contractor Name: First Coast Service Options, Inc. - Full list of policies of this Medicare Contractor

Contractor Number: 09201

Contractor Type: MAC A

LCD Information

LCD ID Number: L38396 Status: A-Approved

LCD Title: Cardiology Non-emergent Outpatient Stress Testing

Geographic Jurisdiction: Puerto Rico, Virgin Islands Other Jurisdictions

Original Determination Effective Date: 03/15/2020

Original Determination Ending Date:

Revision Effective Date: 04/25/2021

Revision End Date:

CMS National Coverage Policy:

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

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 6, Sections 20.4 Outpatient Diagnostic Services and 20.4.1 Diagnostic Services Defined
    • Chapter 15, Sections 50 Drugs and Biologicals and 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
    • Chapter 16, Section 20 Services Not Reasonable and Necessary
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
    • Chapter 1, Part 4, Sections 220.2 Magnetic Resonance Imaging (MRI), 220.5 Ultrasound Diagnostic Procedures, 220.6 Positron Emission Tomography (PET) Scans, 220.6.1 PET for Perfusion of the Heart, 220.6.8 FDG PET for Myocardial Viability, and 220.12 Single Photon Emission Computed Tomography (SPECT)
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 13, Sections 40 Magnetic Resonance Imaging (MRI) Procedures, 50 Nuclear Medicine, 60.11 Coverage for PET scans for Perfusion of the Heart Using Ammonia N-13, 60.2.1 Coverage for Myocardial Viability, 60.3.2 Tracer Codes Required for Positron Emission Tomography (PET) Scans, 60.4 PET Scans for Imaging of the Perfusion of the Heart Using Rubidium 82 (Rb 82), and 60.9 Coverage of PET Scans for Myocardial Viability
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provisions in LCDs

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1861(r)(1) defines “physician” (a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action).
  • Title XVIII of the Social Security Act, Section 1861(s)(3) diagnostic tests covered under the Social Security Act and payable under the physician fee schedule have to be performed under the supervision of an individual meeting the definition of a “physician”.
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Code of Federal Regulations (CFR) References:

  • CFR, Title 42, Volume 2, Chapter IV, Part 410.32(d)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  • CFR, Title 42, Volume 2, Chapter IV, Part 410.33 Independent diagnostic testing facility.
  • CFR, Title 42, Volume 2, Chapter IV, Part 414.50 Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier.

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06/12/2024 08:09:44

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