P28.40 — Unspecified apnea of newborn
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The medical record must contain documentation fully supporting medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Each echocardiography service requires a formal written report with interpretation retained in the record and copies of image documentation (paper or electronic) available for review.
- A complete study must include M-mode and/or 2D measurements of LV end-diastolic diameter, LV end-systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion, and a qualitative description of LV function, or valid substitutes such as LV volumes, ejection fraction, and mass.
- Doppler interrogation must state the modes used and provide both qualitative and quantitative information.
Key Coverage Criteria
- Transthoracic echocardiography (TTE) is covered when the patient's medical record documents medical necessity consistent with the LCD indications for TTE.
- Contrast (contrast-enhanced) echocardiography is covered when conventional echocardiographic studies were inconclusive and contrast enhancement is needed to complete diagnostic evaluation.
- Repeat echocardiographic studies are covered to monitor changes in cardiac structure or function when there is a change in clinical status or when disease progression is suspected.
- TTE is indicated to assess cardiac effects of systemic hypertension, including detection of left ventricular hypertrophy to guide long-term antihypertensive therapy.
- TTE is indicated to evaluate ventricular function, cardiomyopathies, and heart failure when history, physical exam, or routine labs suggest or cannot exclude cardiac disease.
- TTE is indicated in acute myocardial infarction or suspected acute ischemia to evaluate regional wall motion, right ventricular ischemia/infarction, and complications (e.g., mural thrombus, papillary muscle dysfunction, septal defects, aneurysm).
4 Active Policies
A56781 — Billing and Coding: Transthoracic Echocardiography (TTE)
J06
L33577 — Transthoracic Echocardiography (TTE)
J06
AETNA-CPB-0336 — Acoustic Pharyngometers and SNAP Testing System
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.