I25.5 — Ischemic cardiomyopathy
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).
- Patients with a personal history of sustained ventricular tachyarrhythmia (sustained VT) or cardiac arrest due to ventricular fibrillation (VF) not associated with an acute myocardial infarction and not due to a transient or reversible cause are covered for ICD implantation.
- Patients with prior myocardial infarction and measured left ventricular ejection fraction (LVEF) ≤ 0.30 are covered for ICD implantation provided they do not have NYHA class IV heart failure, have not had CABG or PCI within the past 3 months, have not had an MI within the past 40 days, and are not clinical candidates for coronary revascularization.
- Patients with severe ischemic dilated cardiomyopathy without a personal history of sustained VT or cardiac arrest, who have NYHA class II or III heart failure and LVEF ≤ 35% are covered for ICD implantation provided they have not had CABG/PCI within 3 months, have not had an MI within 40 days, and are not candidates for coronary revascularization.
20 Active Policies
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A57479 — Billing and Coding: Percutaneous Coronary Interventions
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L35490 — Category III Codes
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