I07.1 — Rheumatic tricuspid insufficiency
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The patient's medical record must fully document medical necessity for the cardiac catheterization and support the diagnosis and procedures billed.
- Each claim must include ICD-10-CM diagnosis code(s) that accurately reflect the patient's condition and reason for the procedure and these codes must be linked to the CPT procedure codes on the claim.
- When a referring/ordering physician is required, the name and NPI of the referring/ordering physician must be reported on the claim; for extra-cardiac angiographic services the treating physician's name and NPI must be submitted in items 17/17a of CMS-1500 or electronic equivalent.
- For patients post-heart transplant without evidence of rejection, use primary diagnosis Z09 (follow-up after completed treatment) and secondary diagnosis Z94.1 (heart transplant status); add the underlying disorder code when coding I25.82 or I31.4.
Key Coverage Criteria
- Medicare Part B covers the professional component of cardiac catheterization and coronary angiography when performed in hospital inpatient and outpatient facility settings.
- Diagnostic cardiac catheterization performed in an office setting (where permitted) is covered under Medicare Part B for both professional and technical components.
- Global and technical component procedures are covered under Part B when performed under personal physician supervision in an IDTF, free-standing facility, physician office, or physician-directed clinic (physician present in room for entire procedure).
- 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.
- Cardiac catheterization and coronary angiography are covered when the medical record documents medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests that support the procedure.
20 Active Policies
L33577 — Transthoracic Echocardiography (TTE)
J06
L33557 — Cardiac Catheterization and Coronary Angiography
J06
A52850 — Billing and Coding: Cardiac Catheterization and Coronary Angiography
J06
A56781 — Billing and Coding: Transthoracic Echocardiography (TTE)
J06
A56952
Related Codes
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