Notification



Notification Issue Date:



Policy Attachment

Attachment to Policy # MA10.002b


Attachment:A

Policy #:MA10.002b

Description:Medically Necessary ICD-10 Codes

Title:Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Programs


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.



Medically Necessary ICD-10 Codes

I09.81 Rheumatic heart failure

I11.0 Hypertensive heart disease with heart failure

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I20.1 Angina pectoris with documented spasm

I20.8 Other forms of angina pectoris

I20.9 Angina pectoris, unspecified

I21.01: ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02: ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

I23.7 Postinfarction angina

I23.8 Other current complications following acute myocardial infarction

I25.111 Atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm

I25.118 Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris

I25.119 Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

I25.2 Old myocardial infarction

I25.6 Silent myocardial ischemia

I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina pectoris with documented spasm

I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other forms of angina pectoris

I25.709 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unspecified angina pectoris

I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with other forms of angina pectoris

I25.719 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unspecified angina pectoris

I25.721 Atherosclerosis of autologous artery coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.728 Atherosclerosis of autologous artery coronary artery bypass graft(s) with other forms of angina pectoris

I25.729 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unspecified angina pectoris

I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.73 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with other forms of angina pectoris

I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unspecified angina pectoris

I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina pectoris with documented spasm

I25.758 Atherosclerosis of native coronary artery of transplanted heart with other forms of angina pectoris

I25.759 Atherosclerosis of native coronary artery of transplanted heart with unspecified angina pectoris

I25.761 Atherosclerosis of bypass graft of coronary artery of transplanted heart with angina pectoris with documented spasm

I25.768 Atherosclerosis of bypass graft of coronary artery of transplanted heart with other forms of angina pectoris

I25.76 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris

I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris with documented spasm

I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of angina pectoris

I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified angina pectoris

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I50.20 Unspecified systolic (congestive) heart failure

I50.22 Chronic systolic (congestive) heart failure

I50.23 Acute on chronic systolic (congestive) heart failure

I50.30 Unspecified diastolic (congestive) heart failure

I50.32 Chronic diastolic (congestive) heart failure

I50.33 Acute on chronic diastolic (congestive) heart failure

I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart failure

I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart failure

I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure

I50.9 Heart failure, unspecified

Z48.21 Encounter for aftercare following heart transplant

Z48.280Encounter for aftercare following heart-lung transplant

Z94.1 Heart transplant status

Z94.3 Heart and lungs transplant status

Z95.1 Presence of aortocoronary bypass graft

Z95.2 Presence of prosthetic heart valve

Z95.3 Presence of xenogenic heart valve

Z95.4 Presence of other heart-valve replacement

Z95.5 Presence of coronary angioplasty implant and graft

Z98.61 Coronary angioplasty status

Z95.811 Presence of heart assist device

Z95.812 Presence of fully implantable artificial heart

Z95.818 Presence of other cardiac implants and grafts

Z98.890 Other specified postprocedural states

Version Effective Date: 10/01/2017
Version Issued Date: 09/29/2017
Version Reissued Date: 09/26/2019

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