Z87.74 — Personal history of (corrected) congenital malformations of heart and circulatory system
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The claim must include a valid ICD-10-CM diagnosis code that best describes the patient's condition for which the service was performed.
- For diagnostic tests, report the test result if known; if the result is not known, report the symptoms that prompted the test.
- When a referring/ordering physician is required, the referring/ordering physician's name and NPI must be reported on the claim.
- When using modifier -GA an Advance Beneficiary Notice (ABN) Form CMS‑R‑131 should be signed by the beneficiary; for Part A MAC claims include occurrence code 32 and the ABN date.
Key Coverage Criteria
- Echocardiograms performed as part of the CAMZYOS REMS program are covered when billed with modifier KX and all REMS program requirements are met for patients with NYHA Class II–III obstructive hypertrophic cardiomyopathy (I42.1).
- TTE is indicated to evaluate ventricular function, cardiomyopathies, and heart failure, including assessment of myocardial thickness, chamber volumes, and contractility.
- TTE is indicated to evaluate cardiac effects of systemic hypertension when assessment of left ventricular mass or function is clinically relevant to management.
- TTE is indicated for evaluation of suspected or confirmed acute myocardial ischemia/infarction and its mechanical complications, with repeat exams as dictated by the acute clinical course and documented medical necessity.
- TTE is indicated for baseline and serial monitoring of cardiac function in patients exposed to cardiotoxic agents (e.g., doxorubicin), with an initial complete TTE before first administration and repeat studies determined by clinical course (bimonthly during chemotherapy and at ~6 months post-therapy generally appropriate).
- TTE is indicated for donor evaluation and serial monitoring of cardiac allograft recipients for rejection, typically weekly for the first 4–8 weeks post-transplant and then with decremental frequency (approximately two TTEs per year in stable chronic recipients), with higher frequency requiring documentation.
4 Active Policies
AMBETTER-CP.MP.113 — Holter Monitors
AETNA-CPB-0008 — Color-Flow Doppler Echocardiography in Adults
A57306 — Billing and Coding: Transthoracic Echocardiography (TTE)
L34338 — Transthoracic Echocardiography (TTE)
Related Codes
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