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Date Printed: June 26, 2017: 01:19 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. 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.

01-93000-26

Original Effective Date: 01/01/00

Reviewed: 12/03/09

Revised: 11/01/15

Subject: External Counterpulsation (ECP)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

External counterpulsation (ECP), also known as enhanced external counterpulsation (EECP), is a noninvasive procedure that uses timed, sequential inflation of pressure cuffs on the calves, thighs and buttocks to augment diastolic pressure, decrease left ventricular afterload, and increase venous return. Augmenting diastolic pressure places a volume of blood backward into the coronary arteries during diastole when the heart is in a state of relaxation and the resistance in the coronary arteries is at a minimum. The resulting increase in coronary artery perfusion pressure may enhance coronary collateral development or increase flow through existing collaterals. In addition, when the left ventricle contracts, it faces a reduced aortic pressure to work against, since the counterpulsation has somewhat emptied the aorta. EECP has been primarily investigated as a treatment for chronic stable angina.

Under direct supervision of a physician, a full course of therapy usually consists of 35 one-hour treatments, which may be offered once or twice daily, usually 5 days per week. The multiple components of the procedure include the use of the device itself, finger plethysmography to follow the blood flow, continuous EKGs to trigger inflation and deflation, and the optional use of pulse oximetry to measure oxygen saturation before and after treatment. The patient is placed on a treatment table where their lower extremities are wrapped in a series of three compressive air cuffs, which inflate and deflate in synchronization with the patient's cardiac cycle.

During diastole the three sets of air cuffs are inflated sequentially (distal to proximal) compressing the vascular beds within the muscles of the calves, lower thighs and upper thighs. This action results in an increase in diastolic pressure, generation of retrograde arterial blood flow and an increase in venous return. The cuffs are deflated simultaneously just prior to systole, which produces a rapid drop in vascular impedance, a decrease in ventricular workload and an increase in cardiac output.

POSITION STATEMENT:

External counterpulsation (using FDA-approved external counterpulsation systems) meets the definition of medical necessity for individuals with disabling stable angina (Class III or Class IV based on the Canadian Cardiovascular Society Classification scale or equivalent) AND who are not amenable to surgical intervention, such as percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) due to any of the following:

NOTE: This procedure must be performed under direct supervision of a physician. The physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the personnel is performing the service.

Hydraulic versions of ECP devices do not meet the definition of medical necessity. The standard of practice for external counterpulsation does not include the use of hydraulic ECP devices.

For all other indications, specifically for the following conditions, ECP is considered experimental or investigational:

Although there are ongoing clinical studies on the use of ECP for all other indications, the evidence is insufficient to permit conclusions on health outcomes.

BILLING/CODING INFORMATION:

HCPCS Coding:

G0166

External counterpulsation per treatment session

ICD-10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

I20.8

Other forms of angina pectoris

I20.9

Angina pectoris, unspecified

I25.118 – I25.119,
I25.708 – I25.709,
I25.718 – I25.719,
I25.728 – I25.729,
I25.738 – I25.739,
I25.758 – I25.759,
I25.768 – I25.769,
I25.798 – I25.799

Atherosclerosis

REIMBURSEMENT INFORMATION:

External counterpulsation (G0166) is limited to 35 sessions in a twelve (12) month period.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: External Counterpulsation (20.20) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: External Counterpulsation (ECP) (L29171) located at fcso.com.

DEFINITIONS:

Angina pectoris (angina): pain radiating from the heart caused by decreased blood supply to the myocardium.

Atherosclerosis: accumulation of plaque containing cholesterol and lipid material, within the inner walls of arteries.

Cardiac output: the volume of blood ejected by the heart per minute.

Class III angina: Canadian Cardiovascular Society (CCS) functional classification for angina: Marked limitation of ordinary activity. Angina when walking one or two blocks on the level, climbing one flight of stairs at a normal pace.

Class IV angina: Canadian Cardiovascular Society (CCS) functional classification for angina: Inability to carry on any physical activity without discomfort. Angina may be present at rest.

Coronary artery disease: atherosclerotic blockage of the arteries supplying blood to the myocardium.

Diastole: period of expansion or dilatation of the heart ventricles.

Ejection fraction: a clinical cardiac measurement associated with the force and velocity of contraction; ratio of stroke volume to end-diastolic volume; normal resting heart ejects 50 – 60% of its end-diastolic volume with each systole.

Myocardium: the heart muscle.

Retrograde arterial blood flow: blood flow measurement obtained via cardiac catheterization, passing the catheter across the aortic valve into the left ventricle.

Vascular impedance: resistance of blood flow through a particular segment of the circulation.

RELATED GUIDELINES:

End Diastolic Pneumatic Compression Boot as a Treatment of Peripheral Vascular Disease or Lymphedema, 09-E0000-48

OTHER:

The medical record documentation submitted with the claim should include the history and physical, progress notes, OR hospital/office notes and must support that the service was ordered by the physician for a patient with Class III or Class IV angina not amenable to surgical intervention. Medical record documentation is not required to be submitted with claims for services that have an authorization in the Corporate Medical Clearance Application (CMCA).

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician hospital discharge summary

11490-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician Initial Assessment

18736-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician hospital discharge summary

11490-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REFERENCES:

  1. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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:e1–157.
  2. Blue Cross Blue Shield Association Medical Policy. Reference Manual 2.02.06 Enhanced External Counterpulsation (EECP) for Chronic Stable Angina or Congestive Heart Failure, 06/12/08.
  3. Blue Cross Blue Shield Association Technology Evaluation Center Assessment. External Counterpulsation for Treatment of Chronic Stable Angina Pectoris and Chronic Heart Failure. Volume 20, No. 12, 12/05.
  4. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 20.20 NCD for External Counterpulsation, 03/20/06.
  5. ECRI, Target Database, Target Report 233. External Counterpulsation (ECP) for Coronary Indications, 01/05.
  6. First Coast Service Options, Inc, LCD for External counterpulsation (ECP) (L29171), 02/02/09.
  7. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O'Rourke RA, Pasternak RC, Williams SV. American College of Cardiology; American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). 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 Jan; 41(1): 159-68.
  8. Michaels AD, Barsness GW, Soran O, Kelsey SF, Kennard ED, Hui JC, Lawson WE; International EECP Patient Registry Investigators. Frequency and efficacy of repeat enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry). Am J Cardiol. 2005 Feb 1; 95(3): 394-7.
  9. Michaels AD, Raisinghani A, Soran O, de Lame PA, Lemaire ML, Kligfield P, Watson DD, Conti CR, Beller G. The effects of enhanced external counterpulsation on myocardial perfusion in patients with stable angina: a multicenter radionuclide study. Am Heart J. 2005 Nov; 150(5): 1066-73.
  10. Ontario Ministry of Health and Long-Term Care. Enhanced external counterpulsation (EECP): health technology policy assessment update. Toronto: Medical Advisory Secretariat, Ontario Ministry of Health and Long-Term Care (MAS), 2006: 66.
  11. Soran O, Kennard ED, Kfoury AG, Kelsey SF; IEPR Investigators. Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry). Am J Cardiol. 2006 Jan 1; 97(1): 17-20.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 12/03/09.

GUIDELINE UPDATE INFORMATION:

01/01/00

Medical Coverage Guideline developed.

06/15/00

Revision of guideline consisting of the addition of code G0166.

08/23/01

Review of guideline with no changes.

07/15/03

Review and revision of guideline consisting of the addition of limitation.

04/15/05

Review and revision of guideline consisting of updated references and addition of limitation.

03/15/06

Review and revision of guideline consisting of updated references.

03/15/07

Review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline.

03/15/08

Review and revision of guideline consisting of updated references.

02/15/09

Review and revision of guideline consisting of updated references.

12/15/09

Annual review: position statements maintained, references updated.

10/15/10

Revision; related ICD-10 codes added.

07/15/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

10/01/15

Revision; ICD10 coding section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 26, 2017: 01:19 AM