I25.111 — Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
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).
- Cardiac CT (CCT) or Coronary CT Angiography (CCTA) is covered when the patient's medical record documents medical necessity consistent with the indications and limitations set forth in the attached Local Coverage Determination (LCD).
- Cardiovascular nuclear medicine testing is reimbursable for risk assessment or re-evaluation in asymptomatic patients or patients with stable symptoms who have known atherosclerotic heart disease on catheterization or SPECT perfusion imaging, provided the patient has not undergone a revascularization procedure within the prior 2 years.
- Blood pool scan to assess left ventricular ejection fraction prior to implantation of an implantable cardioverter-defibrillator (ICD) or biventricular pacemaker is covered when the medical record documents the intended plan for device insertion and the test result.
20 Active Policies
L35121 — Coronary Computed Tomography Angiography (CCTA)
J05
A57593 — Billing and Coding: Non-Invasive Peripheral Arterial Vascular Studies
J05
L35761 — Non-Invasive Peripheral Arterial Vascular Studies
J05
L39913 — Artificial Intelligence Enabled CT Based Quantitative Coronary Topography (AI-QCT)/Coronary Plaque Analysis (AI-CPA)
J05
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