CPT® 93351; Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for CPT® 93351; Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 93351; Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional. The quarterly edit effectiveness results from July 1, 2025, through September 30, 2025, are as follows:

Top Denial Reasons

  • Denial Reason 1: The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination
  • Denial Reason 2: The requested records were not received.
  • Denial Reason 3: The documentation submitted was incomplete and/or insufficient

Educational Resources

Education

Noridian has a Local Coverage Determinations (LCD) policy for Cardiac Stress Tests. Please visit our website www.noridianmedicare.com to view the LCD L34324 Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography for full coverage guidance.

A cardiovascular stress test is a diagnostic test designed to evaluate a patient for the presence or the severity of coronary artery disease (CAD), exercise-induced arrhythmia or hemodynamic changes, and/or cardiac functional capacity.

Stress echocardiography adds a sound wave image of the heart (echocardiogram) to the electrical monitoring. A two-dimensional (2-D) echocardiographic image of the heart is made and recorded during rest and during exercise. The echocardiography measures exercise-induced changes which offers mechanical evidence of exercise-induced cardiac muscle dysfunction, presumably due to reduced blood flow through one or more diseased coronary arteries.

The LCD lists reasons that a stress echocardiogram would be reasonable and necessary in addition to an electrical stress test. There are instances in which an electrical stress test alone would not be useful or effective and that a stress echocardiogram would be needed. The stress echocardiogram would be reasonable and necessary to aid in diagnosis of hypertrophic or dilated cardiomyopathy. Refer to the LCD for a complete list.

Stress echocardiograms are not reasonable and necessary if performed simultaneously with a radionuclide ventriculography test or with a myocardial perfusion imaging stress test with or without pharmacological stress.

Documentation must support medical necessity of the service this includes a clinical diagnosis, the reason for the stress echocardiogram as opposed to only an electrical stress test, reason for a stress echocardiogram if a stress nuclear test is also performed for the same patient for the same clinical condition. Refer to the LCD for a complete list.

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