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Subject:
Guideline #:
Status:
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
CG-RAD-21
Current Effective Date: 07/07/2010
Revised
05/13/2010
Last Review Date:
Description
This document addresses the use of transesophageal (TEE) and transthoracic (TTE) echocardiography for the
evaluation of individuals with suspected or established cardiovascular disorders in the outpatient setting. For the
purposes of this document, the definition of echocardiography incorporates Doppler analysis, M-mode
echocardiography, two-dimensional TTE, and, when indicated, TEE.
Note: Please see the following related documents for additional information:
• RAD.00002 Positron Emission Tomography and PET/CT Fusion
• RAD.00023 SPECT (Single Photon Emission Computed Tomography) Scans and Scintimammography
• CG-RAD-16 Myocardial Perfusion Imaging in the Outpatient Setting
• CG-RAD-22 Stress Echocardiography in the Outpatient Setting
• CG-RAD-23 Cardiac Blood Pool and Infarct Imaging in the Outpatient Setting
Clinical Indications
A. Transthoracic Echocardiography (TTE)
Medically Necessary:
I. Valvular Heart Disease
Transthoracic echocardiography is considered medically necessary for the evaluation of suspected or established
valvular heart disease when any of the following conditions are present:
1. Heart murmurs, initial evaluation (Note: After valvular disease is established, follow criteria in Section 2.
Valvular heart disease)
• in the presence of cardiorespiratory symptoms; or
• in asymptomatic individuals in whom the clinical features indicate at least a moderate probability of
structural heart disease.
2. Valvular heart disease, suspected or established stenosis or regurgitation
• initial diagnosis: assessment of hemodynamic severity, assessment of left ventricular (LV) and right
ventricular (RV) size, function, and/or hemodynamics; or
• re-evaluation of established valvular disease with changing signs or symptoms suggestive of worsening
valvular disease or cardiac decompensation; or
• re-evaluation in asymptomatic individuals with any of the following:
o severe valvular stenosis (any valve), on an annual basis; or
o severe valvular regurgitation (any valve), on an annual basis; or
o moderate mitral regurgitation with structurally abnormal valve, on an annual basis.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 1 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
•
assessment of changes in hemodynamic severity and ventricular compensation in individuals with
established valvular disease during pregnancy.
3. Mitral valve prolapse (MVP)
• initial diagnosis: assessment of hemodynamic severity, leaflet morphology, and/or ventricular
compensation in individuals with physical signs of MVP; or
• re-evaluation of established MVP with changing signs or symptoms suggestive of worsening valvular
disease or cardiac decompensation.
4. Prosthetic cardiac valves and in individuals who have undergone valve repair
• post intervention baseline studies for valve function (early) and ventricular remodeling (late); or
• re-evaluation of individuals with changing clinical signs and symptoms suggestive of worsening valvular
disease or cardiac decompensation; or
• re-evaluation after baseline studies of individuals with valve replacements or repair with mild to moderate
ventricular dysfunction without changing clinical signs or symptoms; or
• routine re-evaluation of asymptomatic individuals after bioprosthetic valve replacement, every five years;
or
• routine re-evaluation of asymptomatic individuals 18 years of age and younger (during growth and
maturation) to evaluate effect of normal growth on prosthetic valve function, on an annual basis.
5. Infective endocarditis (native or prosthetic valves)
• detection and characterization of valvular lesions or associated abnormalities (e.g. abscesses, shunts), their
hemodynamic severity, and/or ventricular compensation in individuals with documented infective
endocarditis; or
• re-evaluation studies in complex endocarditis (e.g. virulent organism, severe hemodynamic lesion, aortic
valve involvement, persistent fever or bacteremia, clinical change, or symptomatic deterioration); or
• evaluation of individuals with high clinical suspicion of culture-negative endocarditis; or
• evaluation of bacteremia (e.g. staphylococcus bacteremia, fungemia) without a known source.
II. Congenital Heart Disease
Transthoracic echocardiography is considered medically necessary for the evaluation of congenital heart disease
when any of the following conditions are present:
1. Clinically suspected congenital heart disease, as evidenced by
• signs and symptoms such as a murmur, cyanosis; or
• unexplained arterial desaturation; or
• exercise-induced precordial chest pain; or
• exercise-induced syncope; or
• an abnormal electrocardiogram (ECG) or radiograph suggesting congenital heart disease (e.g.
dextrocardia, abnormal pulmonary or visceral situs); or
• initial evaluation of an individual with a suspected chromosomal or genetically transmitted myocardial
disease and dominant inherited abnormalities or syndromes affecting multiple family members (e.g.
Marfan syndrome, Ehlers-Danlos syndrome, Turner syndrome); or
• initial evaluation of an individual with suspected major extra cardiac abnormality associated with a high
incidence of coexisting cardiac abnormality (e.g. Marfan syndrome, Ehlers-Danlos syndrome, Turner
syndrome).
2. Known congenital heart disease
• when there is a change in clinical findings; or
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 2 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
•
for which there is uncertainty as to the original diagnosis or when the precise nature of the structural
abnormalities or hemodynamics is unclear; or
• on a periodic basis in individuals with known congenital heart lesions and for whom ventricular function
and atrioventricular valve regurgitation must be followed, including but not limited to:
o a functional single ventricle after Fontan procedure; or
o transposition of the great vessels after Mustard procedure; or
o L-transposition and ventricular inversion; or
o palliative shunts; or
o on an annual basis for individuals with documented cardiac involvement from a systemic connective
tissue disorder (e.g., Marfan syndrome or Ehlers-Danlos syndrome).
• individuals with known congenital heart disease at risk for secondary pulmonary artery disease, including
but not limited to:
o hemodynamically important, moderate, or large ventricular septal defects; or
o atrial septal defects; or
o a single ventricle.
3. In individuals with repaired (or palliated) congenital heart disease with any of the following:
• undergoing staged surgical correction, 18 years of age and younger; or
• re-evaluation in clinically stable individuals with established disease to facilitate clinical decision-making:
o ages 6 to 18 years, with established complex disease, on a biannual basis (every two years); or
o ages less than 6 years old, on a semiannual basis (every six months).
• change in clinical condition or clinical suspicion of residual defects; or
• suspected or confirmed obstruction of conduits and baffles; or
• LV or RV function that must be followed; or
• when at risk of pulmonary hypertension.
III. Evaluation of Ventricular Function
Transthoracic echocardiography is considered medically necessary for the evaluation of individuals with any of
the following clinical presentations:
1. Suspected cardiomyopathy (e.g. hypertrophic, dilated, infiltrative, ischemic) or clinical diagnosis of heart
failure based on any of the following, including but not limited to:
• dyspnea with clinical signs of heart disease; or
• abnormal physical examination, chest x-ray, elevated B-type natriuretic peptide (BNP); or
• unexplained hypotension; or
• abnormal resting ECG showing bundle branch block, hypertrophy, or possible prior infarction; or
• family history of heritable cardiomyopathy; or
• suspected hypertensive heart disease.
2. Diagnosed or suspected myocarditis.
3. Reassessment of LV size and function in individuals with known LV dysfunction (LV ejection fraction [EF]
less than 55%):
• after a change in clinical status suggestive of worsening or decompensation of cardiac status; or
• when needed to guide ongoing medical therapy in an asymptomatic individual, on an annual basis; or
• in individuals 18 years of age and younger with hypertension, on an annual basis.
4. Exposure to cardiotoxic agents (e.g. trastuzumab, mitoxatrone or anthracyclines):
• to determine baseline function prior to exposure; or
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 3 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
• to determine the advisability of additional or increased dosages during exposure.
5. Prior to or periodically after implantation of pacemaker as part of cardiac resynchronization therapy (CRT).
6. Diseases likely to affect RV function, including but not limited to, chronic lung disease and sleep apnea
syndrome.
7. Prior to or after heart transplantation.
IV. Evaluation of Individuals with Cardiac Arrhythmias
Transthoracic echocardiography is considered medically necessary for the evaluation of cardiac arrhythmias and
palpitations when any of the following conditions are present:
1. Arrhythmias with clinical suspicion of structural heart disease or arrhythmia requiring treatment
• sustained (lasting more than 30 seconds) or nonsustained (more than three beats but lasting less than 30
seconds) ventricular arrhythmia; or
• sustained or nonsustained supraventricular tachycardia, including but not limited to, atrial fibrillation, atrial
flutter, or AV node reentrant tachycardia.
V. Evaluation of Individuals with Known or Suspected Coronary Artery Disease (CAD)
Transthoracic echocardiography is considered medically necessary for the evaluation of acute myocardial ischemic
syndromes when any of the following conditions are present:
1. Diagnosis of acute myocardial syndromes
• suspected acute ischemia or infarction not evident by standard means; or
• for initial assessment of LV function (this study is usually done prior to discharge or within three weeks of
discharge); or
• evaluation of individuals with inferior myocardial infarction and clinical evidence suggesting possible RV
infarction; or
• assessment of mechanical complications (e.g. valvular dysfunction, septal rupture, mural thrombus).
2. Risk assessment, prognosis, and assessment of therapy in acute myocardial syndromes
• assessment of infarct size and/or extent of jeopardized myocardium; or
• for re-evaluation of ventricular function during recovery phase (up to three months following myocardial
infarction) to assess remodeling or when prompted by a change in symptoms; or
• assessment of ventricular function after revascularization, on one occasion.
3. Aberrant or anomalous origin of coronary artery or coronary artery fistula
• initial evaluation, suspected disease; or
• periodic re-evaluation in individuals 18 years of age and younger (during growth and maturation) with an
established diagnosis of aberrant or anomalous coronary origins or coronary artery fistula if the findings on
echocardiography will impact clinical decision making.
4. Kawasaki disease
• initial evaluation, suspected disease; or
• evaluation of an individual with established Kawasaki disease at 6-8 weeks after diagnosis to assess for
coronary artery involvement; or
• re-evaluation of an individual with small or medium-sized coronary artery aneurysms from Kawasaki
disease on an annual basis; or
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 4 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
•
re-evaluation of an individual with large or giant coronary artery aneurysms or coronary artery obstruction
from Kawasaki disease on a semiannual (every six months) basis.
VI. Pulmonary Embolus and Pulmonary Hypertension
Transthoracic echocardiography is considered medically necessary for the evaluation of pulmonary and pulmonary
vascular disease when any of the following conditions are present:
1. Pulmonary emboli and suspected clots in the right atrium or ventricle or main pulmonary artery branches.
2. Initial evaluation of suspected pulmonary hypertension.
3. Periodic re-evaluation of established disease, follow-up of pulmonary artery pressures to evaluate response to
treatment.
4. Dyspnea, for distinguishing cardiac versus noncardiac etiology when other clinical and laboratory findings are
ambiguous.
5. Diseases likely to affect RV function, including but not limited to, chronic lung disease, sleep apnea, or other
causes of cor pulmonale.
6. For measurement of exercise pulmonary artery pressure.
7. Advanced lung disease, prior to lung transplantation or other surgical procedures.
VII. Aortic Disease
Transthoracic echocardiography is considered medically necessary for the evaluation of suspected thoracic aortic
disease for any of the following conditions, including but not limited to:
1. Aortic aneurysm.
2. Aortic dissection
• initial diagnosis, location and extent; or
• follow-up, suspected complication or progression, or
• follow-up, postsurgical repair.
3. Aortic intramural hematoma.
4. Aortic root dilation in an individual with known or suspected (e.g. first-degree relative) Marfan syndrome or
other connective tissue disease (e.g. Ehlers-Danlos syndrome).
5. Aortic rupture.
6. Degenerative or traumatic aortic disease with clinical atheroembolism.
VIII. Pericardial Diseases
Transthoracic echocardiography is considered medically necessary for the evaluation of any of the following:
1. Pericardial effusion
• initial evaluation of suspected disease; or
• re-evaluation of symptomatic and asymptomatic individuals with clinically significant pericardial effusion
to guide medical and surgical decision making.
2. Cardiac tamponade.
3. Pericardial tumors and cysts.
4. Constrictive pericarditis.
5. Post open-heart surgery.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 5 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
IX. Cardiac Masses or Cardiac Source of Embolus
Transthoracic echocardiography is considered medically necessary for the evaluation of any of the following:
1. Cardiac mass, suspected tumor or thrombus
• to diagnose or exclude underlying cardiac disease known to predispose to mass formation (i.e. to assist in a
therapeutic decision regarding surgery or anticoagulation); or
• follow-up or surveillance after surgical removal of masses known to have a high likelihood of recurrence
(i.e. myxoma); or
• as part of disease staging for known primary malignancies with cardiac involvement.
2. Neurological events or other vascular occlusive events when cardioembolic source is suspected and there is no
evidence of other obvious cause.
X. Syncope
Transthoracic echocardiography is considered medically necessary for the evaluation of either of the following:
1. Syncope in an individual with clinically suspected heart disease as indicated by abnormal EKG or abnormal
cardiovascular examination; or
2. Periexertional syncope.
Not Medically Necessary:
Transthoracic echocardiography is considered not medically necessary when the above criteria are not met and for
all other indications, including but not limited to the following:
1. Screening in the general population, including asymptomatic athletes.
2. Evaluation of systemic hypertension without suspected hypertensive heart disease or re-evaluation of
established hypertensive heart disease without a change in clinical status.
3. Native or prosthetic valves in the presence of transient fever but without evidence of bacteremia or new
murmur.
4. To evaluate LV function when:
• prior ventricular function evaluation (e.g. echocardiogram, LV gram, single-photon emission computed
tomography [SPECT], cardiac MRI) was normal within the past year; and
• there has been no change in clinical status.
5. Isolated atrial premature contraction (APC) or premature ventricular contraction (PVC) without other evidence
of heart disease.
6. Initial evaluation of suspected pulmonary embolism in order to establish diagnosis.
7. Routine re-evaluation of individuals with Kawasaki disease if echocardiogram within the first 8 weeks
following initial diagnosis shows no evidence of coronary artery abnormalities.
Transthoracic echocardiography repeated within a 12 month time period is considered not medically necessary
when the above medically necessary criteria are not met, and for all other indications, including but not limited to:
1. Routine evaluation of the following conditions:
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 6 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
•
Asymptomatic individuals with corrected atrial septal defect (ASD), ventricular septal defect (VSD), or
patent ductus arteriosis (PDA) more than one year after successful correction; or
• prosthetic valve with no suspicion of valvular dysfunction and no change in clinical status; or
• hypertrophic cardiomyopathy with no change in clinical status.
2. Routine re-evaluation of the following conditions when there has been no change in the individual’s clinical
status:
• mitral valve prolapse with no or mild mitral regurgitation (MR); or
• mild native aortic stenosis or mild-moderate native mitral stenosis, asymptomatic; or
• native valvular regurgitation with mild regurgitation and normal LV size, asymptomatic; or
• heart failure (systolic or diastolic).
B. Transesophageal Echocardiography (TEE)
Medically Necessary:
Transesophageal echocardiography is considered medically necessary as an adjunct or subsequent test to
transthoracic echocardiography when suboptimal TTE images preclude obtaining a diagnostic study.
Transesophageal echocardiography is considered medically necessary in an individual who has, or is likely to have
suboptimal TTE imaging for any of the following:
1. When TTE image quality is suboptimal such that the clinical question(s) prompting the TEE has/have not been
adequately answered.
2. When it is likely that TTE will be suboptimal in the following situations:
• previous TTE was of suboptimal quality; or
• the individual has characteristics or severe abnormalities that preclude obtaining a diagnostic TTE,
including but not limited to, severe abnormalities of thoracic contour, recent thoracic surgery, severe chest
wall abnormalities, or following severe chest trauma or extensive burns to the thorax.
Transesophageal echocardiography is considered medically necessary as the initial test for any of the following
indications, including but not limited to:
1. Evaluation of acute aortic pathology, suspected, including dissection/transsection.
2. To determine the mechanism of regurgitation and suitability of valve repair.
3. To diagnose/manage endocarditis with a moderate or high pre-test probability (e.g., bacteremia, especially
staph bacteremia or fungemia).
4. Evaluation of persistent fever in individuals with intracardiac device.
5. Evaluation of atrial fibrillation or atrial flutter to facilitate clinical decision-making regarding anticoagulation,
cardioversion, radiofrequency ablation or any combination of these interventions.
6. Evaluation of individuals who have undergone surgical correction of complex congenital heart disease when
there is a suspicion of intracardiac thrombus.
Not Medically Necessary:
Transesophageal echocardiography is considered not medically necessary for evaluation of individuals with any
of the following:
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 7 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
1. Cardiovascular source of embolic event, as initial test, when all of the following are present:
• normal TTE; and
• normal ECG; and
• no history of atrial fibrillation or atrial flutter.
2. Atrial fibrillation or atrial flutter for left atrial thrombus when a decision has been made to anticoagulate and
not to perform cardioversion.
Coding
The following codes for treatments and procedures applicable to this document are included below for
informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or
imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect
at the time of service to determine coverage or non-coverage of these services as it applies to an individual
member.
CPT
93303
93304
93306
93307
93308
93312
93313
93314
93315
93316
93317
93320
Transthoracic echocardiography (TTE)
Transthoracic echocardiography for congenital cardiac anomalies; complete
Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited
study
Echocardiography, transthoracic, real-time with image documentation (2D), includes Mmode recording, when performed, complete, with spectral Doppler echocardiography, and
with color flow Doppler echocardiography
Echocardiography, transthoracic, real-time with image documentation (2D), includes Mmode recording, when performed, complete, without spectral or color Doppler
echocardiography
Echocardiography, transthoracic, real-time with image documentation (2D), includes Mmode recording, when performed, follow-up or limited study
Transesophageal echocardiography (TEE)
Echocardiography, transesophageal, real-time with image documentation (2D) (with or
without M-mode recording); including probe placement, image acquisition, interpretation
and report
Echocardiography, transesophageal, real-time with image documentation (2D) (with or
without M-mode recording); placement of transesophageal probe only
Echocardiography, transesophageal, real-time with image documentation (2D) (with or
without M-mode recording); image acquisition, interpretation and report only
Transesophageal echocardiography for congenital cardiac anomalies; including probe
placement, image acquisition, interpretation and report
Transesophageal echocardiography for congenital cardiac anomalies; placement of
transesophageal probe only
Transesophageal echocardiography for congenital cardiac anomalies; image acquisition,
interpretation and report only
Additional components
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display;
complete [in addition to 93303, 93304, 93312, 93314, 93315, 93317]
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 8 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
93321
93325
HCPCS
C8921
C8922
C8923
C8924
C8925
C8926
C8929
Doppler echocardiography, pulsed wave and/or continuous wave with spectral display;
follow-up or limited study [in addition to 93303, 93304, 93308, 93312, 93314, 93315,
93317]
Doppler echocardiography color flow velocity mapping [in addition to 93303, 93304,
93308, 93312, 93314, 93315, 93317]
Transthoracic echocardiography with contrast, or without contrast followed by with
contrast, for congenital cardiac anomalies; complete
Transthoracic echocardiography with contrast, or without contrast followed by with
contrast, for congenital cardiac anomalies; follow-up or limited study
Transthoracic echocardiography with contrast, or without contrast followed by with
contrast, real-time with image documentation (2D) with or without M-mode recording;
complete
Transthoracic echocardiography with contrast, or without contrast followed by with
contrast, real-time with image documentation (2D) with or without M-mode recording;
follow-up or limited study
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by
with contrast, real time with image documentation (2D) (with or without M-mode
recording); including probe placement, image acquisition, interpretation and report
Transesophageal echocardiography (TEE) with contrast, or without contrast followed by
with contrast, for congenital cardiac anomalies; including probe placement, image
acquisition, interpretation and report
Transthoracic echocardiography with contrast, or without contrast followed by with
contrast, real-time with image documentation (2D), includes M-mode recording, when
performed, complete, with spectral Doppler echocardiography, and with color flow
Doppler echocardiography
ICD-9 Diagnosis
All diagnoses
Discussion/General Information
According to the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Cheitlin, 2003), the use of echocardiography in establishing cardiac diagnoses and making therapeutic decisions, at
times without further diagnostic studies, is well established. Echocardiography is a painless test that uses sound
waves to create images of the heart, specifically, showing the size, structure, and movement of the different parts of
the heart, including the valves, the septum (the wall separating the chambers on the right and left sides of the heart),
and the walls of the heart chambers. Echocardiography can be used to diagnose heart problems, guide or determine
next steps for treatment, monitor changes and improvement, and determine the need for additional tests.
Some of these heart problems identified by echocardiography may pose no risk to the individual. Others may be
signs of serious heart disease or other heart problems. An echocardiogram can provide information on the
following:
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 9 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
• Size of the heart. An enlarged heart can be the result of high blood pressure, leaky heart valves, or heart
•
•
•
•
failure. Weakened areas of heart muscle can be due to damage from a heart attack. Or weakening could mean
that the area isn’t getting enough blood supply, which can be due to coronary artery disease.
Heart valve abnormality. Echocardiography can identify whether any of the heart valves do not open normally
or fail to form a complete seal when closed.
Abnormalities in the structure of the heart. Echocardiography can detect a variety of heart abnormalities, such
as a hole in the septum (the wall that separates the two chambers on the left side of the heart from the two
chambers on the right side) and other congenital heart defects (structural problems present at birth).
Condition of the aorta. Echocardiography is commonly used to assess and detect problems with the aorta such
as aneurysm (abnormal bulge or “ballooning” in the wall of an artery).
Blood clots or tumors. Echocardiography may be performed to check if a blood clot or tumor has been the
cause of a stroke or related condition.
Congenital structural heart disease is the most common type of cardiovascular disease in the pediatric population.
According to Cheitlin and colleagues (2008), acquired heart disease also contributes to the cardiovascular morbidity
of this population. Acquired pediatric heart disease historically was identified with rheumatic fever and
endocarditis, but now includes Kawasaki disease (Newburger, 2004) and other coronary arterial diseases, human
immunodeficiency virus (HIV) and other viral-related cardiac disease, dilated cardiomyopathy with or without
acute-onset congestive heart failure, hypertrophic cardiomyopathy, and an increasing population with clinical
cardiovascular issues related to surgical palliation/correction of structural heart disease and cardiac transplantation.
Two-dimensional Doppler echocardiography has become the definitive diagnostic method for the recognition and
assessment of congenial and acquired heart disease in the pediatric population. Re-evaluation echocardiographic
examinations are frequently used to monitor cardiovascular adaptation to surgical repair or palliation and identify
reoccurrence of abnormalities. Longitudinal follow-up studies facilitate proactive surgical and/or medical
interventions that improve outcomes by guiding management decisions, and providing early education and support
for the families of pediatric and adolescent individuals (Cheitlin, 2008).
A transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are different imaging
studies that allow for initial evaluation and screening of suspected heart disease, or re-evaluation of known heart
disease and related conditions. TTE is considered a standard test, while TEE is used if a TTE or other standard tests
fail to produce clear results (AHA, 2009; NHLBI, 2009).
Description of Transthoracic Echocardiography
Echocardiography, particularly transthoracic two-dimensional and Doppler echocardiography, is one of the most
important and frequently performed diagnostic procedures for individuals with cardiovascular disease. TTE
involves the use of ultra-high frequency sound waves (ultrasound) directed through the chest wall to produce an
image of the motion of the heart chambers, valves, major vessels, and pericardium in a noninvasive and
instantaneous manner. The widely accepted cardiovascular indications for the procedure include, but are not limited
to the diagnosis of and guiding treatment for: coronary artery disease, valvular heart disease, heart failure,
hypertensive heart disease, congenital abnormalities, complications of pulmonary disease, and others (Quiñones,
2003).
TTE is usually performed in the cardiology department at a hospital, but may also be performed in a cardiologist's
office or an outpatient imaging center. Because the ultrasound scanners used to perform echocardiography may be
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 10 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
portable (handheld) or mobile, echocardiography can be performed in the hospital's emergency department or at the
individual’s bedside when the individual cannot be transported to the cardiology department.
The standard TTE examination generally takes less than 30 minutes and does not require any special preparation.
The individual lies bare-chested on an examination table. A special gel is spread over the chest to help a wand-like
device, called a transducer, make contact and slide smoothly over the skin. The transducer is a small handheld
device at the end of a flexible cable that functions essentially as a modified microphone. When placed against the
chest, it directs ultrasound waves into the chest. Some of the waves get echoed (or reflected) back to the transducer.
Since different tissues and blood reflect ultrasound waves differently, these sound waves can be translated into a
meaningful image of the heart that can be displayed on a monitor or recorded on paper or tape. TTE is associated
with little discomfort, and no risks have been identified with this procedure. The individual usually resumes normal
activities immediately after TTE.
Occasionally, variations of the echocardiography test are used. For example, Doppler echocardiography employs a
special microphone that allows technicians to measure and analyze the direction and speed of blood flow through
blood vessels and heart valves. This makes it especially useful for detecting and evaluating regurgitation through
the heart valves. By assessing the speed of blood flow at different locations around an obstruction, it can also help
to precisely locate the obstruction.
Description of Transesophageal Echocardiography
A TEE is particularly useful for examining the heart and great vessels and identifying posterior structures, such as
the pulmonary vein, left atrium, and mitral valve. Its clinical applications include, but are not limited to, detection
and assessment of endocarditis and its complications, aortic dissection and other aortic pathologies, intracardiac
thrombi and other masses, evaluation of valvular disorders including prosthetic valve function, and evaluation of a
variety of chronic heart diseases in both children and adults. TEE is also used in individuals with suspected cardiac
trauma, in critically ill medical or surgical individuals with unstable hemodynamics, and in individuals whose
clinical status necessitates echocardiographic assessment but in whom TTE studies are technically inadequate or
non-diagnostic (Quiñones, 2003). A TEE requires the insertion of a transducer (probe) attached to a fiberoptic
endoscope that is guided down the anesthetized throat into the esophagus and stomach. The transducer transmits the
ultrasound waves capable of producing clear images of the heart structures without interference of the lungs and
chest. Because placement of the probe is invasive it may require conscious sedation. Associated risks include a
serious reaction to the sedation or local anesthetic administered prior to and during the procedure, difficulty
breathing, or nausea. The procedure involves some discomfort and minimal but definite risk of pharyngeal and
esophageal trauma and even rarely esophageal perforation. Rare instances of infective endocarditis have been
associated with the use of TEE (Cheitlin, 2003).
Definitions
Contrast echocardiography: echocardiography used to demonstrated abnormalities in blood flow; the ultrasonic
beam tracks microbubbles produced by intravenous injection of a liquid or a small amount of carbon dioxide gas as
the contrast medium
Doppler echocardiography: a technique for recording the flow of red blood cells through the cardiovascular
system by means of Doppler ultrasonongraphy, either continuous wave or pulsed wave
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 11 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
Echocardiography: also called ultrasound cardiography; the use of ultrasound to map and take “moving pictures”
of the heart with sound waves; the recording of the size, motion, and structure of various cardiac structures to aid in
the diagnosis of cardiovascular disease
M-mode echocardiography: echocardiography that records the amplitude and rate of motion (M) in real time,
yielding a mono-dimensional (“icepick”) view of the heart
Transesophageal echocardiography (TEE): an ultrasound of the heart that uses a special echocardiography
transducer (ultrasound camera) inserted through the mouth, down the back of the throat, and into the esophagus to
provide cardiographic images or Doppler information
Transthoracic echocardiography (TTE): a non-invasive test that uses beams of ultrasound waves directed
through the chest wall to record the position and motion of the heart walls or internal structures of the heart
References
Peer Reviewed Publications:
1. Chu VH, Bayer AS. Use of echocardiography in the diagnosis and management of infective endocarditis. Curr
Infect Dis Rep. 2007; 9(4):283-290.
2. Hung J, Lang R, Flachskampf F, et al. 3D echocardiography: a review of the current status and future
directions. J Am Soc Echocardiogr. 2007; 20(3):213-233.
3. Kirkpatrick JN, Ky B, Rahmouni HW, et al. Application of appropriateness criteria in outpatient transthoracic
echocardiography. J Am Soc Echocardiogr. 2009; 22(1):53-59.
4. Klein AL, Grimm RA, Murray RD, et al. Role of transesophageal echocardiography-guided cardioversion of
patients with atrial fibrillation. J Am Coll Cardiol. 2006; 48:e1-148.
5. Nagueh SF, Appleton CP, Gillebert TC, et al. Recommendations for the evaluation of left ventricular diastolic
function by echocardiography. J Am Soc Echocardiogr. 2009; 22(2):107-133.
6. Roy PM, Colombet I, Durieux P, et al. Systematic review and meta-analysis of strategies for the diagnosis of
suspected pulmonary embolism. BMJ. 2005; 331(7511):259.
Government Agency, Medical Society, and Other Authoritative Publications:
1. American Academy of Pediatrics (AAP). Guidelines for pediatric cardiovascular centers. Pediatrics. 2002;
109(3):544-549. Available at: http://pediatrics.aappublications.org/cgi/reprint/109/3/544. Accessed on March
12, 2010.
2. American College of Radiology. ACR Appropriateness Criteria®. Available at:
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria.aspx. Accessed on March 12,
2010.
• Acute Chest Pain - Low Probability of Coronary Artery Disease (2008).
• Acute Chest Pain - Suspected Aortic Dissection (2008).
• Acute Chest Pain - Suspected Pulmonary Embolism (2006).
• Chronic Chest Pain - High Probability of Coronary Artery Disease (2006).
• Chronic Chest Pain - Low to Intermediate Probability of Coronary Artery Disease (2008).
• Shortness of Breath - Suspected Cardiac Origin (2006).
• Suspected Bacterial Endocarditis (2006).
• Suspected Congenital Heart Disease in the Adult (2007).
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 12 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
3. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with
unstable angina/non–ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial
Infarction): developed in collaboration with the American College of Emergency Physicians, American College
of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50(7):e1-157.
4. Ayres NA, Miller-Hance W, Fyfe DA, et al. Indications and guidelines for performance of transesophageal
echocardiography in the patient with pediatric acquired or congenital heart disease: report from the task force of
the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr. 2005; 18(1):9198.
5. Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: European
Association of Echocardiography/American Society of Echocardiography recommendations for clinical
practice. J Am Soc Echocardiogr. 2009; 22(1):1-23.
6. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with
valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with
valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists
endorsed by the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic
Surgeons. J Am Coll Cardiol. 2006; 48(3):e1-148.
7. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006
guidelines for the management of patients with valvular heart disease: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the
1998 guidelines for the management of patients with valvular heart disease) endorsed by the Society of
Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2008; 52(13):e1-142.
8. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 guideline update for the clinical
application of echocardiography. Summary article: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997
Guidelines for the Clinical Application of Echocardiography). Circulation. 2003; 108(9):1146-1162.
9. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007
appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American
College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working
Group, American Society of Echocardiography, American College of Emergency Physicians, American Society
of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular
Computed Tomography, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2007;
50(2):187-204.
10. Fleisher L, Beckman J, Brown K, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation
and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative
Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of
Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular
Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine
and Biology, and Society for Vascular Surgery. J Am Coll Cardiol, 2007; 50(17):159-242.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 13 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
11. Fraker TD, Fihn SD. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the
management of patients with chronic stable angina: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines Writing Group to Develop the Focused Update of the
2002 Guidelines for the Management of Patients with Chronic Stable Angina. J Am Coll Cardiol, 2007;
50(23):2264-2274.
12. Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients
with chronic stable angina - summary article: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable
Angina). J Am Coll Cardiol. 2003; 41(1):159-168.
13. Lai WW, Geva T, Shirali GS, et al. Guidelines and standards for performance of a pediatric echocardiogram: a
report from the Task Force of the Pediatric Council of the American Society of Echocardiography. J Am Soc
Echocardiogr. 2006; 19(12):1413-1430.
14. Maron BJ, Thompson PD, Ackerman MJ, et al. Recommendations and considerations related to
preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific
statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism:
endorsed by the American College of Cardiology Foundation. Circulation. 2007; 115(12):1643-1655.
15. Newburger JW, Takahashi M, Gerber MA, et al. Committee on Rheumatic Fever, Endocarditis and Kawasaki
Disease; Council on Cardiovascular Disease in the Young; American Heart Association; American Academy of
Pediatrics. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health
professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on
Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004; 110(17):2747-2771.
16. Quiñones MA, Douglas PS, Foster E, et al. ACC/AHA/ACP-ASIM/ASE/SCAI/SPE. ACC/AHA clinical
competence statement on echocardiography: a report of the American College of Cardiology/American Heart
Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical
Competence. J Am Coll Cardiol. 2003; 41(4):687-708.
17. Strickberger SA, Benson DW, Biaggioni I, et al. AHA/ACCF scientific statement on the evaluation of syncope:
from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing,
Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research
Interdisciplinary Working Group; and the American College of Cardiology Foundation In Collaboration With
the Heart Rhythm Society. J Am Coll Cardiol. 2006; 47(2):473-484.
18. Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with
echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's
Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with
the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the
American Heart Association, the European Association of Echocardiography, a registered branch of the
European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of
Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association,
European Association of Echocardiography, a registered branch of the European Society of Cardiology, the
Japanese Society of Echocardiography, and Canadian Society of Echocardiography. J Am Soc Echocardiogr.
2009; 22(9):975-1014.
19. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. American Society of Echocardiography. Recommendations
for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler
echocardiography. J Am Soc Echocardiogr. 2003; 16(7):777-802.
Web Sites for Additional Information
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 14 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
1. American College of Cardiology (ACC). Clinical Statements/Guidelines. Available at:
http://www.acc.org/qualityandscience/clinical/statements.htm. Accessed on March 12, 2010.
2. American Heart Association (AHA). Available at:
http://www.americanheart.org/presenter.jhtml?identifier=1200000. Accessed on March 12, 2010.
3. American Society of Echocardiography (ASE) Available at:
http://www.asecho.org/i4a/pages/index.cfm?pageid=1. Accessed on March 12, 2010.
4. National Heart, Lung, and Blood Institute (NHLBI). Diseases and Conditions Index: Echocardiography.
Available at: http://www.nhlbi.nih.gov/health/dci/Diseases/echo/echo_all.html. Accessed on March 12, 2010.
Index
Acute Myocardial Ischemic Syndrome
Angina
Aortic Stenosis
Cardiac Arrhythmias
Cardiomyopathy
Chest Pain
Congenital Heart Disease
Coronary Artery Disease
Echocardiography
Endocarditis
Heart Murmur
Hypertrophic Cardiomyopathy
Infective Endocarditis
Ischemic Heart Disease
Left Ventricular Dysfunction
Mitral Regurgitation
Mitral Valve Prolapse
Myocardial Infarction
Native Valve
Pericardial Disease
Prosthetic Valve
Pulmonary Embolus
Pulmonary Hypertension
Syncope
Thoracic Aortic Disease
Transesophageal Echocardiography
Transthoracic Echocardiography
Valvular Heart Disease
Valvular Regurgitation
The use of specific product names is illustrative only. It is not intended to be a recommendation of one
product over another, and is not intended to represent a complete listing of all products available.
Document History
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 15 of 16
Clinical UM Guideline
CG-RAD-21
Transesophageal and Transthoracic Echocardiography in the Outpatient Setting
Status
Revised
Date
05/13/2010
Revised
08/27/2009
New
05/21/2009
Action
Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised medically necessary criteria for TTE for annual monitoring of severe
valvular stenosis and vavular regurgitation in asymptomatic individuals, to
include (any valve), on an annual basis. Revised medically necessary criteria
for monitoring valve replacement or repair in asymptomatic individuals, 18
years of age and younger (during growth and maturation) to evaluate effect of
normal growth on prosthetic valve function, on an annual basis. Revised
indications for evaluation of ventricular function, adding: “including but not
limited to” (Suspected cardiomyopathy…), chest x-ray and elevated B-type
natriuretic peptide (BNP) to specific criteria in item 1; criterion for diagnosed
or suspected myocarditis; criterion for reassessment of LV size and function in
individuals with known LV dysfunction (LV ejection fraction [EF] less than
55%), including limiting asymptomatic re-evaluation of clinically stable LV
dysfunction to no more often than an annual TTE. Addition of specific
medically necessary criteria for TTE for reassessment of LV size and function
in individuals 18 years of age and younger (during growth and maturation)
with hypertension, on an annual basis. Revised criteria for TTE for exposure
to cardiotoxic agents, adding mitoxantrone to list of agents and statements for
when testing is medically necessary; clarified criterion for TTE testing prior to
or after heart transplantation. For TTE for the diagnosis of acute myocardial
syndromes, revised medically necessary statement for initial assessment of LV
function (done prior to discharge or within three weeks of discharge); for risk
assessment, prognosis, and assessment of therapy in acute myocardial
syndromes, revised statement for re-evaluation of ventricular function during
recovery phase (up to three months following myocardial infarction) to assess
remodeling or when prompted by a change in symptoms. For pulmonary
embolus and pulmonary hypertension, expanded TTE criterion to diseases
likely to affect RV function, including but not limited to, chronic lung disease,
sleep apnea, or other causes of cor pulmonale. Updated Coding and
References.
MPTAC review. Revised medically necessary clinical indications: 1) added
indications for TTE for syncope in Section X. 2) added TTE criteria for
asymptomatic follow-up of clinically significant pericardial effusion in
Section VIII; 3) removed TTE for assessment of pericardial thickness from
Section VIII. Updated Discussion/General information and References.
MPTAC review. Initial document development.
Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, and Medical Policy take precedence over
Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services
are rendered must be used. Clinical UM Guidelines, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.
Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying,
or otherwise, without permission from the health plan.
© CPT Only – American Medical Association
Page 16 of 16