78454
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.31
Facility
$39.76
Non-Facility
$39.76
Documentation Required
- All documentation must be maintained in the patient's medical record, be legible, include complete patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- Every submitted medical record page must include the legible signature of the physician or non-physician practitioner responsible for and providing the care.
- The submitted medical record must support the use of the selected ICD-10-CM code(s) and the submitted CPT/HCPCS code must accurately describe the service performed.
- If the service provider differs from the ordering/referring physician, the performing provider must maintain hard copy documentation of test results and interpretation plus copies of the ordering/referring physician’s order for the studies.
Key Coverage Criteria
- Coverage for non-emergent outpatient stress testing is subject to the reasonable and necessary requirements in Local Coverage Determination L35083 and is allowed only when L35083 clinical criteria are met.
- Preoperative cardiac stress testing with radionuclide imaging for asymptomatic patients deemed at moderate risk is covered only if the medical record documents at least one of the following: diabetes mellitus with complications; peripheral vascular disease; aortic aneurysm; or cerebrovascular disease.
- For services that require a referring or ordering physician, the claim must report the referring/ordering physician's name and NPI.
- Claims must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed; otherwise the claim will be returned as incomplete under SSA Section 1833(e).
- For diagnostic tests, the claim should report the test result if known, otherwise report the symptoms that prompted the test.
- If a service is likely to be non-covered, an Advance Beneficiary Notice (ABN) may be used and the appropriate modifier (GA, GX, GY, or GZ) should be appended to the claim as applicable.
19 Active Policies
L33560 — Cardiovascular Nuclear Medicine
J06
A56743 — Billing and Coding: Cardiovascular Nuclear Medicine
J06
L38396 — Cardiology Non-emergent Outpatient Stress Testing
J09
L33693 — Peripheral Venous Ultrasound
J09
A56952 — Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing
Related Codes
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