Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography

The following coding and billing guidance is to be used with its associated Local coverage determination. Supportive documentation evidencing the condition and treatment is expected to be documented in the medical record and be available upon request. Documentation in the patient’s medical record must substantiate the medical necessity of the service, including the following: • A clinical diagnosis, • The specific reason for the study, • Reason for performing a stress echocardiogram as opposed to only an electrical stress test, • The reason for using any pharmacological stress, and • The reason for a stress echocardiogram if a stress nuclear test is also performed for the same patient for the same clinical condition. Document the referral order (written or verbal) in the patient’s medical record. For example, if a referring physician calls a cardiologist to order a stress echocardiogram, the test report or office record must document the date of the call, name of the referring physician, and reason for referral. Document the interpretation and report of all segments of the service (e.g., the electrical and echo results). Document the necessity for the test frequency, when applicable. Document (preferably on the test report) that any applicable physician supervision requirement is met. For tests performed by leased employees, maintain the leasing contract on file (e.g., in the office) and submit it to the contractor for review upon request. Utilization Guidelines: Stress testing is covered only at a frequency appropriate for the patient’s condition, and when the results will potentially affect the patient’s treatment. A routine follow-up test after an MI, CABG, or PTCA, in the absence of symptoms or clinical indications, outside of the reassessment period, is not reasonable and necessary. Annual testing in the absence of individualized clinical indications is not reasonable and necessary. For example, a patient who has had a MI, CABG, PTCA, or other coronary revascularization procedure may require an initial follow-up stress test several months later and a second test one year after the first follow-up test. Thereafter, a patient who initially presented with silent coronary disease (no reliable signs or symptoms) may require testing as often as annually. However, a patient who initially presented with reliable symptoms or signs of CAD (e.g., angina pectoris) typically will not need annual testing. When the clinical information is sufficient to reliably monitor the patient, an additional follow-up test once every five years may be sufficient.