I25.112 — Atherosclerotic heart disease of native coronary artery with refractory angina pectoris
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
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.
- CPT 78434 (gated SPECT) may be reported only in conjunction with CPT 78431 or CPT 78492 when billed for SPECT myocardial perfusion imaging (MPI).
- SPECT MPI includes routine evaluation of left ventricular wall motion and left ventricular ejection fraction (LVEF) as part of the MP1 service definition.
- Holter monitoring (CPT 93224-93227) is covered for up to 48 hours of continuous recording when progress notes document medical necessity.
- Wearable external mobile cardiac telemetry (CPT 93228 professional, 93229 technical) is covered as one unit per course of treatment that includes up to 30 consecutive days of cardiac monitoring when the documented services (hook-up, transmission, analysis, daily reports, equipment and supplies, and physician review) are provided.
- Long-term continuous recorders (CPT 93241-93248) that continuously record and store for greater than 48 hours up to 7 days, or greater than 7 days up to 15 days, are covered in the outpatient setting when documentation supports medical necessity.
20 Active Policies
L35761 — Non-Invasive Peripheral Arterial Vascular Studies
J05
A57552 — Billing and Coding: Coronary Computed Tomography Angiography (CCTA)
J05
L36523 — MolDX: Biomarkers in Cardiovascular Risk Assessment
J05
L35490 — Category III Codes
J05
L34636
Related Codes
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