About this policy
Percutaneous insertion of an endovascular cardiac assist device requires documentation supporting the diagnosis of the following 3 life-threatening situations when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient: Cardiogenic shock ICD-10-CM code R57.0; or Severe decompensated heart failure with threatening multi-organ failure, represented by one of the following ICD-10 codes: I50.21, I50.23, I50.41, I50.43, I97.110, I97.111, I97.130, I97.131; or Complications/disturbances of the circulatory system intra-operatively or postoperatively: I97.790, I97.791, I97.88 and I97.89. Part A Providers: ICD-10-PCS codes: 5A02116 - Assistance with Cardiac Output using Other Pump, Intermittent 5A0211D -Assistance with Cardiac Output using Impeller Pump, Intermittent 5A02216 - Assistance with Cardiac Output using Other Pump, Continuous 5A0221D - Assistance with Cardiac Output using Impeller Pump, Continuous For Part A Services only, the provider should bill the appropriate procedure code on the UB-04 as this is an inpatient only procedure.
Documentation requirements
Percutaneous insertion of an endovascular cardiac assist device requires documentation supporting the diagnosis of the following 3 life-threatening situations when external counterpulsation (intraaortic balloon pump, IABP) is not expected to be sufficient:
Title XVIII of the Social Security Act (SSA) §1833(e) prohibits Medicare payment for any claim lacking the necessary documentation to process the claim
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 33990 | HCPCS | Covered |
| 33991 | HCPCS | Covered |
| 33992 | HCPCS | Covered |
| 33993 | HCPCS | Covered |
| 33995 | HCPCS | Covered |
| 33997 | HCPCS | Covered |
| I50.21 | ICD10CM | Covered |
| I50.23 | ICD10CM | Covered |
| I50.41 | ICD10CM | Covered |
| I50.43 | ICD10CM | Covered |
| I97.110 | ICD10CM | Covered |
| I97.111 | ICD10CM | Covered |