US CMS Reimbursement FAQs

Medical insurance reimbursement is an important issue for all medical diagnostic tests. The following are frequently asked questions about reimbursement details in the USA.

 

ABPM

Q. For what indication(s) does Medicare reimburse for ABPM?

Q. What is the definition of white-coat hypertension?

Q. What is the amount of reimbursement?

Q. What are the Current Procedural Terminology (CPT) codes for ABPM?

Q. When billing Medicare what ICD-9 code should be used?

A. For answers to these commonly asked questions about ABPM reimbursement in the US, please click the button below and download our 2 page ABPM Reimbursement Information Sheet.

Get My Free US ABPM Reimbursement Guidelines

 

Cardiovascular/Exercise Stress Test

Q. For what indications does Medicare reimburse for a Cardiovascular/Exercise Stress Test?

A. The indications are as follows:

  • To determine the location, presence and severity of exercise induced myocardial ischemia
  • Evaluate potential for rhythm disturbances
  • Evaluate hemodynamic responses to activity
  • Evaluate the effect of medical or interventional therapy
  • Prescribe appropriate activity guidelines
  • Pre-operative evaluation of patients at high risk for coronary artery disease who are scheduled to undergo general anesthesia and/or undergo a surgical procedure which places them at risk for a sudden cardiac event.
  • Establish prognosis and management decisions following an uncomplicated myocardial infarction.
  • Determine whether underlying coronary artery disease is the etiology of unexplained left ventricular dysfunction
  • Assess for recurrent ischemia in patients with prior percutaneious intervention who are at increased risk for restenosis.

Q. What is the amount of reimbursement?

A. The rates for reimbursement can vary by geographical region, insurance company policies, and patient conditions. It is important that you contact your Medicare contractor to verify reimbursement amounts for your region.

Q. What are the CPT codes for Exercise Stress Testing?

A. To view the CPT codes for reimbursement, please click here.

 

Pulse Oximetry

Q. For what indications does Medicare reimburse for Pulse Oximetry?

A. Medicare will allow a separate payment for oximetry when medically necessary to evaluate conditions which are commonly associated with oxygen desaturation:

  • The patient exhibits signs or symptoms of acute respiratory dysfunction (tachypnea; dyspnea; cyanosis; respiratory distress; confusion; hypoxia; severe chest pain)
  • The patient has chronic lung disease, chest trauma, severe cardiopulmonary disease, or neuron-muscular disease involving the muscles of respiration, and oximetry is needed for evaluation of the patient's condition.
  • The patient is under treatment with a medication with known pulmonary toxicity.

Q. What is the amount of reimbursement?

A. The rates for reimbursement can vary by geographical region, insurance company policies, and patient conditions. It is important that you contact your Medicare contractor to verify reimbursement amounts for your region.

Q. What are the CPT codes for Pulse Oximetry?

A. To view the CPT codes for reimbursement, please click here.

Reimbursement Information for Tango+

Applicable CPT codes and clinical indications for Exercise Stress Test

CPT Codes

93015

Cardiovascular stress test using maximal or sub maximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report.

93016

Physician supervision only, without interpretation and report

93017

Tracing only, without interpretation and report

93018

Interpretation and report only

J0150

Injection, Adenosine, per 6 mg

J0152

Injection, Adenosine for diagnostic use, 90 mg

J1245

Injection, Dipyridamole (Persantine), per 10 mg

J1250

Injection, Dobutamine, per 250 mg

ICD-9 Codes

394.0-394.9

Diseases of mitral valve

395.0-395.9

Diseases of aortic valve

396.0-396.9

Diseases of mitral and aortic valves

402.00-402.91

Hypertensive heart disease

404.00-404.93

Hypertensive heart and kidney disease

410.00-410.92

Acute myocardial infarction

411.0-411.89

Other acute and subacute forms of ischemic heart disease

412

Old myocardial infarction

413.0-413.9

Angina pectoris

414.00-414.9

Other forms of chronic ischemic heart disease

416.0 – 416.9

Chronic pulmonary heart disease

424.0-424.3

Other diseases of endocardium

425.0-425.9

Cardiomyopathy

426.0-426.9

Conduction disorders

427.0-427.9

Cardiac dysrhythmias

428.0-428.9

Heart failure

429.0-429.9

Ill defined descriptions and complications of heart disease

780.2

Syncope and collapse

780.4

Dizziness and giddiness

785.50

Shock without mention of trauma

785.51

Cardiogenic shock

785.52

Septic shock

786.02

Orthopnea

786.05

Shortness of breath

786.50-786.59

Chest pain

794.31

Abnormal electrocardiogram

996.72

Other complications of cardiac device or graft

996.83

Complication of transplanted heart

V15.1

Personal history of surgery to heart and great vessels

V42.1

Heart replaced by transplant

V42.2

Heart valve replaced by transplant

V42.6

Lung replaced by transplant

V43.4

Heart valve replaced by other means

Applicable CPT codes and clinical indications for Pulse Oximetry

CPT Codes

94760

Noninvasive ear or pulse oximetry for oxygen saturation; single determination

96761

Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise).

ICD-9 Codes

011.00-011.96

Tuberculosis of lung infiltrative confirmation unspecified – unspecified pulmonary tuberculosis tubercle bacilli not found by bacteriological histological examination but tuberculosis confirmed by other methods.

020.3-020.5

Primary pneumonic plague – pneumonic plague unspecified

021.2

Pulmonary tularemia

039.1

Pulmonary actinomycotic infection

052.1

Varicella (hemorrhagic pneumonitis)

073.0

Ornithosis with pneumonia

079.82

SARS-associated coronavirus infection

130.4

Pneumonitis due to toxoplasmosis

135

Sarcoidosis

136.3

Pneumocystosis

162.0-162.9

Malignant neoplasm of trachea – malignant neoplasm of bronchus and lung unspecified

163.0 – 163.9

Malignant neoplasm of pleura

197.0

Secondary malignant neoplasm of lung

277.00

Cystic fibrosis without meconium ileus

277.01

Cystic fibrosis with meconium ileus

277.02

Cystic fibrosis with pulmonary manifestations

277.03

Cystic fibrosis with gastrointestinal manifestations

277.09

Cystic fibrosis with other manifestations

289.0

Polycythemia secondary

293.0

Delirium due to conditions classified elsewhere

327.09

Other organic insomnia

327.21

Primary central sleep apnea

327.23

Obstructive sleep apnea (adult) (pediatric)

327.29

Other organic sleep apnea

335.20

Amyotrophic lateral sclerosis

357.0

Acute infective polyneuritis

358.00

Myasthenia gravis without (acute) exacerbation

358.01

Myasthenia gravis with (acute) exacerbation

391.8

Other acute pneumatic heart disease

392.0

Rheumatic chorea with heart involvement

398.91

Rheumatic heart failure (congestive)

402.01

Malignant hypertensive heart disease with heart failure

402.11

Benign hypertensive heart disease with heart failure

402.91

Unspecified hypertensive heart disease with heart failure

404.91

Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage I through Stage IV, or unspecified

404.93

Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease Stage V or end stage renal disease

415.0

Acute cor pulmonale

415.11

Iatrogenic pulmonary embolism and infarction

415.12

Septic pulmonary embolism

416.0

Primary pulmonary hypertension

416.9

Chronic pulmonary heart disease unspecified

427.89

Other specified cardiac dysrhythmias

428.0

Congestive heart failure unspecified

428.1

Left heart failure

428.20-428.23

Unspecified systolic heart failure – acute on chronic systolic heart failure

428.30-428.33

Unspecified diastolic heart failure – acute on chronic diastolic heart failure

428.40-428.43

Unspecified combined systolic and diastolic heart failure – acute on chronic combined systolic and diastolic heart failure

428.9

Heart failure unspecified

464.51

Supraglottitis unspecified with obstruction

466.0-466.19

Acute bronchitis – acute bronciolitis due to other infectious organisms

478.30-478.34

Unspecified paralysis of vocal cords – complete bilateral paralysis of vocal cords

478.6

Edema of larynx

478.70

Unspecified disease of larynx

478.71

Cellulitis and perichondritis of larynx

478.74

Stenosis of larynx

478.75

Laryngeal spasm

478.79

Other diseases of larynx

478.8

Upper respiratory tract hypersensitivity reaction site unspecified

480.0

Pneumonia due to adenovirus

480.1

Pneumonia due to respiratory syncytial virus

480.2

Pneumonia due to parainfluenza virus

480.3

Pneumonia due SARS-associated coronavirus

480.8

Pneumonia due to other virus not elsewhere classified

480.9

Viral pneumonia unspecified

481

Pneumococcal pneumonia (streptococcus pneumoniae pneumonia)

482.1

Pneumonia due to pseudomonas

482.30-482.39

Pneumonia due to streptococcus unspecified – pneumonia due to other streptococcus

482.40

Pneumonia due to staphylococcus unspecified

482.41

Pneumonia due to staphylococcus aureus

482.49

Other staphylococcus pneumonia

482.81-482.89

Pneumonia due to anaerobes – pneumonia due to other specified bacteria

483.0-483.8

Pneumonia due to mycoplasma pneumoniae – pneumonia due to other specified organism

484.1-484.8

Pneumonia in cytomegalic inclusion disease – pneumonia in other infectious diseases classified elsewhere.

485

Bronchopneumonia organism unspecified

486

Pneumonia organism unspecified

487.0

Influenza with pneumonia

487.1

Influenza with other respiratory manifestations

488

Influenza due to identified avian influenza virus

490

Bronchitis not specified as acute or chronic

491.1

Mucopurulent chronic bronchitis

491.20-491.21

Obstructive chronic bronchitis without exacerbation – obstructive chronic bronchitis with (acute) exacerbation

491.8

Other chronic bronchitis

491.9

Unspecified chronic bronchitis

492.0

Emphysematous bleb

492.8

Other emphysema

493.00-493.01

Extrinsic asthma unspecified – extrinsic asthma with status asthmaticus

493.10-493.11

Intrinsic asthma unspecified – intrinsic asthma with status asthmaticus

493.20-493.21

Chronic obstructive asthma unspecified – chronic obstructive asthma with status asthmaticus

493.81

Exercise-induced bronchospasm

493.82

Cough variant asthma

493.90-493.91

Asthma unspecified – asthma unspecified type with status asthmaticus

494.0-494.1

Bronchiectasis without acute exacerbation – bronchiectasis with acute exacerbation

495.0-495.9

Farmers’ lung – unspecified allergic alveolitis and pneumonitis

496

Chronic airway obstruction not elsewhere classified

500

Coal workers’ pneumoconiosis

501

Asbestosis

502

Pneumoconiosis due to other silica or silicates

503

Pneumoconiosis due to other inorganic dust

504

Pneumonopathy due to inhalation of other dust

505

Pneumoconiosis unspecified

506.0-506.9

Bronchitis and pneumonitis due to fumes and vapors – unspecified respiratory conditions due to fumes and vapors

507.0-507.8

Pneumonitis due to inhalation of food or vomitus – pneumonitis due to other solids and liquids

508.0-508.9

Acute pulmonary manifestations due to radiation – respiratory conditions due to unspecified external agent

510.0-510.9

Empyema with fistula – empyema without fistula

511.0-511.9

Pleurisy without effusion or current tuberculosis – unspecified pleural effusion

512.0-512.8

Spontaneous tension pneumothorax – other spontaneous pneumothorax

513.0-513.1

Abscess of lung – abscess of mediastinum

514

Pulmonary congestion and hypostasis

515

Postinflammatory pulmonary fibrosis

516.0-516.9

Pulmonary alveolar proteinosis – unspecified alveolar and parietoalveolar pneumonopathy

517.1

Rheumatic pneumonia

517.2

Lung involvement in systemic sclerosis

517.3

Acute chest syndrome

519.4

Disorders of diaphragm

710.1

Systemic sclerosis

714.81

Rheumatoid lung

748.61

Congenital bronchiectasis

780.01-780.09

Coma – alteration of consciousness other

780.39

Other convulsions

780.51

Insomnia with sleep apnea, unspecified

780.53

Hypersomnia with sleep apnea, unspecified

780.57

Unspecified sleep apnea

782.5

Cyanosis

785.0

Tachycardia unspecified

785.50

Shock unspecified

785.51

Cardiogenic shock

785.52

Septic shock

785.59

Other shock without trauma

786.00-786.09

Respiratory abnormality unspecified – respiratory abnormality other

786.3

Hemoptysis

786.50-786.59

Unspecified chest pain – other chest pain

786.6

Swelling mass or lump in chest

793.1

Nonspecific abnormal findings on radiological and other examination of lung field

799.01-799.1

Asphyxia - respiratory

807.4

Flail chest

958.7

Traumatic subcutaneous emphysema

987.9

Toxic effect of unspecified gas fume or vapor

997.3

Respiratory complications not elsewhere classified

998.81

Emphysema (subcutaneous) (surgical) resulting from procedure

V01.82

Exposure to SARS-associated coronavirus

V42.6

Lung replaced by transplant

V58.69

Long-term (current) use of other medications

V67.2

Follow-up examination following chemotherapy