CMS Cardiac Output Monitoring by Thoracic Electrical Bioimpedance Coverage Policy: What Billing Teams Need to Know (NCD 267)

The Centers for Medicare & Medicaid Services has updated its coverage policy for thoracic electrical bioimpedance (TEB) cardiac output monitoring under NCD 267. This modification clarifies exactly when Medicare will and will not pay for this non-invasive hemodynamic monitoring technology—and the distinctions matter significantly for cardiology, heart failure, and cardiac device practices billing these services.

What Changed: CMS NCD 267 TEB Policy Modification

The original Medicare coverage determination for TEB, effective July 1, 1999, covered the technology broadly for "noninvasive diagnosis or monitoring of hemodynamics in patients with suspected or known cardiovascular disease." CMS found that language too vague—insufficiently defined and inadequately supported by clinical literature to give practitioners meaningful guidance on when coverage applied.

In response to a formal request for reconsideration, CMS overhauled the policy language to provide explicit covered indications, hard exclusions, and a carve-out for Medicare Administrative Contractor (MAC) discretion in one specific clinical scenario. The revised policy took initial effect January 23, 2004, was further refined on November 24, 2006, and this 2026 modification reflects continued policy maintenance under NCD 267.

If your practice has been billing TEB services under a general "hemodynamic monitoring" rationale, this policy update is a documentation wake-up call.

Medicare TEB Coverage: The Five Nationally Covered Indications

CMS has established five specific clinical scenarios where TEB monitoring is covered under Medicare. For each indication, coverage is conditional—the treating physician must document that standard assessment tools were insufficient and that TEB hemodynamic data were necessary for appropriate patient management.

1. Acute Dyspnea Differentiation
TEB is covered to differentiate cardiogenic from pulmonary causes of acute dyspnea when medical history, physical examination, and standard assessment tools don't provide enough information. Documentation must reflect the clinical gap that made TEB necessary.

2. A/V Interval Optimization for Pacemaker Patients
For patients with atrioventricular (A/V) sequential cardiac pacemakers, TEB is covered to optimize the A/V interval when standard workup is insufficient. This is a common indication in electrophysiology and cardiac device clinics—make sure your EP documentation explicitly states why standard tools fell short.

3. Continuous Inotropic Therapy Monitoring
TEB is covered for monitoring continuous inotropic therapy in two specific patient groups: those with terminal congestive heart failure who have elected comfort-focused care at home, and patients awaiting heart transplant at home. The home-setting element matters for billing—this is not a general inpatient inotrope monitoring indication.

4. Post-Transplant Rejection Evaluation
TEB is covered as a predetermined alternative to myocardial biopsy for evaluating rejection in heart transplant patients. If a biopsy is ultimately performed after TEB, medical necessity for the biopsy must be separately documented. This two-step documentation requirement is easy to miss.

5. Fluid Management Optimization in CHF
For congestive heart failure patients, TEB is covered to optimize fluid management when history, exam, and standard tools don't provide sufficient information. Given the high volume of CHF patients in Medicare populations, this is likely the most frequently billed indication—and the one most likely to face scrutiny without strong supporting documentation.

Medicare TEB Non-Coverage: Hard Exclusions Your Team Must Know

CMS is equally explicit about what it will not cover. Four patient populations are categorically excluded from TEB coverage:

1. Severe aortic regurgitation — Patients with proven or suspected severe regurgitation of the aorta are non-covered. This affects a meaningful subset of valvular disease patients.

2. Minute ventilation sensor pacemakers — TEB is non-covered for patients with MV sensor function pacemakers because the electrical signals from TEB devices can adversely affect pacemaker function. This is a safety-driven exclusion, not just a billing rule—flag it in your EHR workflows.

3. Cardiac bypass surgery — TEB is non-covered during cardiac bypass surgery.

4. Hypertension management (with one exception) — TEB is non-covered for managing all forms of hypertension. The sole exception is drug-resistant hypertension, which falls under MAC discretion (see below).

Any claim submitted for these excluded indications faces denial regardless of documentation quality. Train your pre-authorization and charge-capture teams to screen against this list at the point of scheduling.

The Drug-Resistant Hypertension Exception: MAC Discretion Applies

CMS does not nationally cover TEB for hypertension management—but it explicitly carves out drug-resistant hypertension for local coverage determination by Medicare Administrative Contractors. Drug-resistant hypertension is defined as failure to achieve goal blood pressure in patients adhering to full doses of an appropriate three-drug regimen that includes a diuretic.

If your practice sees patients meeting this definition, check with your regional MAC to determine whether a Local Coverage Determination (LCD) exists for this indication in your jurisdiction. National non-coverage does not automatically mean your MAC has not established coverage locally.

Affected Codes

The policy document for NCD 267 does not list specific CPT or HCPCS codes. Billing teams should work directly with their MAC and reference the CMS National Coverage Determinations Manual to confirm the appropriate procedure codes for TEB services. Contact your MAC's provider outreach line or consult your coding reference for the applicable HCPCS L-codes or CPT codes associated with TEB device use and hemodynamic monitoring interpretation.

What Your Billing Team Should Do