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Date Printed: June 23, 2017: 06:19 PM

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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.

01-93000-29

Original Effective Date: 02/15/00

Reviewed: 05/26/11

Revised: 11/01/15

Subject: Thoracic Electrical Bioimpedance (TEB)

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:

Bioimpedance is defined as the electrical resistance of tissue to the flow of current. For example, when small electrical signals are transmitted through the thorax, the current travels along the blood-filled aorta, which is the most conductive area. Changes in bioimpedance, measured at each beat of the heart, are inversely related to pulsatile changes in volume and velocity of blood in the aorta. Cardiac output is the product of stroke volume by heart rate, and thus can be calculated from bioimpedance. Cardiac output is generally reduced in patients with systolic heart failure. Acute decomposition is characterized by worsening of cardiac output from the patient’s baseline status. The technique is alternatively known as impedance plethysmography and impedance cardiography (ICG).

The BioZĀ® (SonoSite, Bothell, WA) thoracic impedance plethysmograph was cleared for marketing by the FDA through the 510(k) process in June 1997. Several other impedance plethysmographs have been approved through the same process. The FDA determined that this device was substantially equivalent to existing devices for use in peripheral blood flow monitoring.

POSITION STATEMENT:

Thoracic electrical bioimpedance (TEB) meets the definition of medical necessity for the following indications:

Thoracic electrical bioimpedance is experimental or investigational as there is insufficient clinical evidence to support the use of thoracic electrical bioimpedance for all other indications, and specifically for the following conditions:

Scientific evidence is scarce regarding thoracic electrical bioimpedance reporting patient outcomes for the above experimental or investigational indications. There is insufficient evidence for formulating meaningful conclusions on the clinical utility of thoracic electrical impedance.

BILLING/CODING INFORMATION:

CPT Coding:

93701

Bioimpedance derived physiologic cardiovascular analysis

Bioimpedance relies on the same technology as plethysmography. Although bioimpedance provides only a regional measure of the thorax, providers may be seen inappropriately using CPT code 94726 for total body plethysmography when reporting cardiac bioimpedance.

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

I01.0 – I01.9

Rheumatic fever with heart involvement

I05.0 – I05.9
I06.0 – I06.9
I07.0 – I07.9
I08.0 – I08.9
I09.0 – I09.2
I09.81
I09.89
I09.9

Chronic rheumatic heart diseases

I11.0

Hypertensive heart disease with heart failure

I13.0 – I13.2

Hypertensive heart and chronic kidney disease

I20.0 – I20.9

Angina pectoris

I21.01 – I21.09
I21.11 – I21.19
I21.21 – I21.29
I21.3
I21.4

ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction

I22.0 – I22.9

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction

I24.0 – I24.9

Other acute ischemic heart diseases

I25.10
I25.110 – I25.119
I25.2 – I25.3
I25.41 – I25.42
I25.5
I25.6
I25.700 – I25.709
I25.710 – I25.719
I25.720 – I25.729
I25.730 – I25.739
I25.750 – I25.759
I25.790 – I25.799
I25.810 – I25.812
I25.82 – I25.89
I25.9

Chronic ischemic heart disease

I26.01 – I26.09
I26.90 – I26.99

Pulmonary embolism

I27.0 – I27.2
I27.81 – I27.89
I27.9

Other pulmonary heart diseases

I30.0 – I30.9

Acute pericarditis

I31.0 – I32

Other diseases of pericardium

I32.0 – I31.9
I32

Acute and subacute endocarditis

I33.0

Acute and subacute infective endocarditis

I33.9

Acute and subacute endocarditis

I34.0 – I34.9

Nonrheumatic mitral valve disorders

I36.0 – I36.9

Nonrheumatic tricuspid valve disorders

I37.0 – I37.9

Nonrheumatic pulmonary valve disorders

I39

Endocarditis and heart valve disorders in diseases classified elsewhere

I40.0 – I40.9

Acute myocarditis

I41

Myocarditis in diseases classified elsewhere

I42.0 – I42.9

Cardiomyopathy

I43

Cardiomyopathy in diseases classified elsewhere

I50.1 – I50.9

Rheumatic mitral valve diseases

I51.7

Cardiomegaly

I51.81

Takotsubo syndrome

I60.00 – I60.9

Nontraumatic subarachnoid hemorrhage

I97.0
I97.110-I97.111
I97.120-I97.121
I97.130.-I19.131
I97.190-I97.191

Intraoperative and postprocedural complications and disorders of circulatory system, not elsewhere classified

J81.0

Acute pulmonary edema

J95.84

Transfusion-related acute lung injury (TRALI)

R06.00 – R06.09

Dyspnea

T86.20 – T86.23
T86.290-T86.298

Complications of heart transplant

T86.30 – T86.39

Complications of heart-lung transplant

Z45.010 – Z45.018

Encounter for checking and testing of cardiac pacemaker

Z94.1

Heart transplant status

Z95.0

Presence of cardiac pacemaker

REIMBURSEMENT INFORMATION:

Reimbursement for cardiac output by electrical bioimpedance is limited to four (4) in a 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: Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB) (20.16) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (L29091) located at fcso.com

DEFINITIONS:

Bioimpedance: the electrical resistance of tissue to the flow of current.

Cardiac output: equals the stroke volume multiplied by the heart rate.

Inotropic therapy: cardiotonic; increases the tonicity of the heart using various drugs (i.e., digitalis).

Plethysmography: recording of the changing of the size of a part as modified by the circulation of the blood in it.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report Thoracic Electrical Bioimpedance:

Note: 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.

Cardiac Electrical Bioimpedance
Thoracic Bioimpedance
Plethysmography
Bioimpedance Cardiography
BioZ™

REFERENCES:

  1. Blue Cross Blue Shield Association Medical Policy Reference Manual, 2.02.12 Noninvasive Measurements of Cardiac Hemodynamics in the Outpatient Setting. 02/09/10.
  2. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 1, Section 20.16 Cardiac Output Monitoring by Thoracic Electrical Bioimpedance (TEB). 01/16/07.
  3. Florida Medicare Part B Local Coverage Determination. L 29091 Cardiac Output Monitoring by Thoracic Electrical Bioimpedance, 01/01/10.
  4. Hayes, Inc. Hayes Medical Technology Directory. Electrical Bioimpedance for the Measurement of Cardiac Output Lansdale, PA: Hayes Inc.; January 2003. Updated March 2008.
  5. Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). American College of Cardiology Web Site.
  6. Jordan H S, Ioannidis J P, Goudas L C, Chung M, Kupelnick B, Miller K, Terrin N, Lau J. and the Tufts-New England Medical Center AHRQ Evidence-based Practice Center (EPC). Thoracic electrical bioimpedance. EPC Technical Support of the CPTA Technology Assessment Program. Contract No. 290-97-0019, Task Order #10. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); revised November 27, 2002.
  7. Smith RD, Levy P, Ferrario CM; Consideration of Noninvasive Hemodynamic Monitoring to Target Reduction of Blood Pressure Levels Study Group. Value of noninvasive hemodynamics to achieve blood pressure control in hypertensive subjects. Hypertension. 2006 Apr; 47(4): 771-7.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/26/11.

GUIDELINE UPDATE INFORMATION:

02/15/00

New Medical Coverage Guideline.

01/01/02

HCPCS Coding changes.

02/15/03

Reviewed; no changes.

03/15/04

Annual review. References updated. MCG name changed to Thoracic Electrical Bioimpedance (TEB). Changes to coverage criteria. MCG changed to Active but no longer scheduled for routine review.

05/15/08

Review and revision of guideline consisting of references.

06/15/09

Scheduled review; no change in position statement.

01/01/10

Annual HCPCS coding update: revise description for CPT 93701.

10/15/10

Revision; related ICD-10 codes added.

06/15/11

Scheduled review; Position Statement unchanged; references updated.

01/01/12

Annual HCPCS coding update: reference to CPT codes 93720, 93721, and 93722 replaced with new code 94726.

05/15/14

Revision; Program Exceptions section updated.

10/01/15

Revision; updated ICD9 and ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: June 23, 2017: 06:19 PM