CPT CODE - 78451, 78452 - 78496, a4641. a9500, j0152 - Cardiovascular Nuclear Medicine

procedure code and description


78452 - Ht muscle image spect mult - average fee payment - $500 - $510

78451 Myocardial perfusion SPECT single study including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest or stress

Nuclear Cardiac Imaging and Myocardial Perfusion Study Procedure codes

78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78452  Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

The most commonly performed myocardial perfusion imaging are single (at rest or stress, Procedure 78451) and multiple (at rest and stress, Procedure 78452) tomographic SPECT studies.



Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Noninvasive testing in the outpatient setting to assess coronary artery disease (CAD) and left ventricular (LV) dysfunction may be accomplished utilizing conventional exercise testing or by measuring the distribution of nuclear medicine reagents during physiologic or pharmacologic stress.

    Cardiovascular stress testing, also called an exercise stress test (EST), exercise electrocardiogram, exercise treadmill test (ETT), graded exercise test, or stress electrocardiogram (ECG), is used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while the electrocardiogram, heart rate, and blood pressure are monitored. The same measurement may be obtained with the substitution of echocardiography for a standard ECG. Echocardiography is used to image cardiac structures and function and also flow direction and velocities within cardiac chambers and vessels. Usually these images are obtained from several positions on the chest wall and abdomen using a hand-held transducer.

    In many instances, exercise testing (without imaging) may be combined with imaging procedures, such as myocardial perfusion imaging, radionuclide ventriculography, echocardiography, or other imaging procedures.

    There are 3 principle types of stress tests which do not involve the measurement of radio-labelled distribution within the body. These include:

    • Exercise stress test (EST) is normally the first stress test performed. The patient walks on a treadmill or similar device while being monitored to measure endurance with an end-point of symptoms, ECG, or echocardiographic changes that suggest coronary under-perfusion. EST is without imaging. An EST must include an ECG that can be interpreted for ischemia, and the patient must be capable of exercise on a treadmill or similar device generally at 4 METs or greater (i.e., able to walk four blocks without stopping, can climb two flights of stairs without stopping). An abnormal EST includes any one of the following: ST segment depression, development of chest pain, significant arrhythmia (especially ventricular arrhythmia), or hypotension.

    • Dobutamine, Dipyridamole, or Adenosine Stress Test is used in people who are unable to exercise. A drug is given to make the heart respond as if the person were exercising. This way the doctor can still determine how the heart responds to stress, but no exercise is required.

    • Stress echocardiogram is a graphic outline of the heart's movement. A stress echo can accurately visualize the motion of the heart's walls and pumping action when the heart is stressed; it may reveal a lack of blood flow that isn't always apparent on other heart tests.

    The main task of Nuclear Cardiology and Nuclear Medicine is not the representation of anatomy, as in traditional Diagnostic Radiology; rather, it is the non-invasive visualization of functional, metabolic processes. In diagnostic Nuclear Medicine, the subject first incorporates tracer amounts of a radioactively-labelled molecule. Once the tracer molecule is properly distributed inside the body, imaging techniques visualize the metabolism of the substance by measuring the distribution of the radioactively-labelled molecule through externally emitted radiation.

Cardiovascular nuclear imaging employs non-invasive techniques to assess alterations in coronary artery flow, as well as ventricular function. A variety of radionuclides may be used, including Technetium tc-99M sestamibi, thallium 201 and Technetium tc-99M tetrofosim.

The specific imaging technique (perfusion versus ventricular function) and the reason for the imaging determine what radionuclide agent is employed. In its simplest terms, a perfusion study utilizes an imaging isotope agent that reflects myocardial blood flow and, dependent on the agent and timing of image acquisition, the presence of scar and/or ischemia. Ventricular function studies utilize specific imaging isotopes to outline the borders of the left ventricular endocardium or to identify the ventricular blood pool independent of the surrounding myocardium. The motion of the left ventricle is synchronized with the electrocardiogram to generate wall motion and ejection fraction information. Both modalities may use rest and exercise images.

In instances where an exercise test cannot be performed, dipyridamole, adenosine or other provocative agents may be used to alter coronary flow, thereby unmasking a suspected lesion in the coronary bed. The acquisition of the images may be planar (single plane) or by multiple planes with computer integration, Single-Photon Emission Computer Tomography (SPECT).


Indications

Radionuclide imaging may be employed in the assessment of a variety of conditions associated with primary coronary artery disease. Some of these conditions include:

  • Assessment of the functional level and prognosis of patients afflicted with angina or coronary artery disease.
  • Diagnostic evaluation of patients with chest pain or other signs and symptoms highly suggestive of ischemic heart disease and who have uninterpretable or equivocal ECG changes caused by drugs, bundle branch block or left ventricular hypertrophy.
  • Evaluation of myocardial perfusion and or function before and after coronary artery bypass surgery or other reperfusion procedures.
  • Quantification and surveillance of myocardial infarction and aid in the determination of the prognosis in patients with infarction.
  • Assessment of anomalies of coronary circulation in certain congenital forms.
Imaging techniques are also used for:
  • Evaluation of ventricular function in patients with non-ischemic myocardial disease, including myocardial disease due to valvular heart diseases.
  • Evaluation of a patient receiving chemotherapeutic drugs that are potentially cardiotoxic (e.g., adriamycin).
  • Assessment of viable myocardium and non-viable myocardium in patients anticipating partial myocardial surgical resection.
  • Assessment of ventricular function and/or myocardial perfusion in patients in whom major vascular, thoracic, CNS or intra-abdominal surgery is planned.
Patient selection should be based on clinical grounds. Patients with a high pretest probability of disease are not usually candidates for a study for diagnostic purposes, though the size and reversibility of a defect and its functional consequences may be required for clinical decision-making. Patients with a moderate probability of disease benefit the most from the study when the diagnosis is in question. Additionally, selection of the test should be made within the context of other testing modalities so the expected information does not become redundant.

Limitations

  • Given the limitations of uptake, low photon energy and redistribution, the cardiac blood pool codes and perfusion imaging codes are not generally covered on the same date of service. However, in light of the predictive value of exercise-induced changes in ejection fraction, an exception will be made to allow first pass, single study with exercise along with the appropriate perfusion studies. Providers who bill this service must certify within their records that their laboratories are specially equipped to process such studies.
  • All cardiovascular nuclear tests and stress tests must be referred by a physician or a qualified non-physician. (i.e., a Nurse Practitioner (NP) or Physician Assistant (PA)).
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 18X, 21X, 71X, 85X
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of shortCPT descriptors in policies published on the Web.
78451©
Ht muscle image spect, sing
78452©
Ht muscle image spect, mult
78453©
Ht muscle image, planar, sing
78454©
Ht musc image, planar, mult
78466©
Heart infarct image
78468©
Heart infarct image (ef)
78469©
Heart infarct image (3d)
78472©
Gated heart, planar, single
78473©
Gated heart, multiple
78481©
Heart first pass, single
78483©
Heart first pass, multiple
78494©
Heart image, spect
78496©
Heart first pass add-on
A4641
Radiopharmaceutical, diagnostic, not otherwise classified
A9500
Technetium tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries
A9502
Technetium tc-99m tetrofosmin, diagnostic, per study dose
A9505
Thallium tl-201 thallous chloride, diagnostic, per millicurie
J0152
Injection, adenosine for diagnostic use, 30 mg (not to be used to report any adenosine phosphate compounds; instead use A9270)
J0395
Injection, arbutamine hcl, 1 mg
J1245
Injection, dipyridamole, per 10 mg
J1250
Injection, dobutamine hydrochloride, per 250 mg
J2785
Injection, regadenoson, 0.1 mg



Billing and Coding Guidelines


Q: Which CPT codes should be used when describing MPI SPECT studies?

CPT CODE 78451 - Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

CPT CODE 78452 - Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 

93015-93018: Cardiovascular stress testing. Choose appropriate code(s) from the stress test series.

*** Note: Also bill any appropriate HCPCS code for the use of radiopharmaceuticals or drugs administered during the MPI study or stress test.***



Q: How do MPI Planar studies differ from MPI SPECT studies?

A: While SPECT technology allows the nuclear cardiologist to view a threedimensional image of a specific area, planar imaging only produces a two-dimensional image. Most nuclear cardiologists utilize SPECT imaging because it allows them to finely examine an image in multiple planes. Procedure  codes 78453 and 78454 are used to describe MPI Planar studies.




Q: The above example used 78452 to describe the imaging study. Can I use any of the CPT codes that describe MPI SPECT?


A: No! When deciding which code to use for any procedure, it is critical that coders select the name of the procedure or service that accurately identifies the service performed and not just choose a CPT code that merely approximates the service provided. 



Myocardial Perfusion Imaging, Tomographic

78451 78452


Example #1:


An authorization is given for CPT code 78451 “Myocardial perfusion imaging, tomographic (SPECT); single study, at rest or stress”. The cardiologist performs CPT code 78452 “Myocardial perfusion imaging, tomographic (SPECT); multiple studies, at rest and/or stress and/or redistribution and/or rest reinjection”. The provider does not need to contact Care to Care to modify the authorization as CPT code 78452 is included in the same code group as CPT code 78451.



Question:

Which modifier can I use when billing 93010, 93016, 93018, and 78452? Medicare denied 93010, 93016, and 93018 because, the
procedure or the procedure with a modifier are not compatible. Illinois Subscriber


Answer:

You can’t report 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; supervision only, without interpretation and report) and 93018 (... interpretation and report only) together. There’s a combined CPT® code to report all three components of a cardiovascular stress test: 93015 (... with supervision, interpretation and report). 


The CPT® codes that you should use are:

78452-TC (Myocardial perfusion imaging,  tomographic [SPECT] [including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed]; multiple studies, at rest and/or stress [exercise or pharmacologic] and/or redistribution and/or rest reinjection) for the imaging. Add modifier TC (Technical component) to show that your provider performed the report and interpretation but does not
own the equipment.  

   Coverage  Limitations:

        The CMS Manual System, Pub. 100-8, Program Integrity Manual, Chapter 13, Section 5.1, outlines that "reasonable and necessary" services are "ordered and/or furnished by qualified personnel." Services will be considered medically reasonable and necessary only if performed by appropriately trained providers. A qualified physician for this service/procedure is defined as follows: A) Physician is properly enrolled in Medicare. B) Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty in the United States or must reflect equivalent education, training, and expertise endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States.


        The presence of risk factors for CAD, absent disease activity, is not a Medicare-covered indication for noninvasive testing. Screening for coronary artery disease in asymptomatic patients is not considered reasonable and necessary.


        Patient selection should be based on clinical grounds. Pretest probability is based on age, gender, symptoms, and cardiac risk factors. Selection of the test should be made within the context of other testing modalities so that the expected information does not become redundant. In the instance where regional wall motion abnormalities and ejection fraction have been assessed, during the same episode of care, by other testing modalities (i.e. echocardiography), the medical necessity of repeating this assessment through the use of nuclear imaging modalities must be clearly documented in the medical record. The routine and repetitive monitoring of such patients beyond the first stress echo or MPI, in the absence of a documented clinical exacerbation (i.e., new symptoms or progression of existing symptoms) is not considered medically necessary.


        MPI SPECT/PET and stress echo are not covered in patients with low pretest probability, interpretable ECG, and the ability to exercise.


        MPI SPECT/PET and stress echo pre-operative evaluation for low risk non-cardiac surgery is not covered.


        MPI SPECT/PET and stress echo are not covered for the pre-operative evaluation of planned intermediate risk, non-cardiac surgery, and the patient is able to exercise.


        MPI SPECT/PET and stress echo are not covered for routine risk assessment for asymptomatic patients with known CAD, who have not had a revascularization procedure.


        MPI SPECT/PET and stress echo are not covered for pre-operative, asymptomatic patients undergoing high risk non-cardiac surgery up to 1 year following normal stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization.


        Exercise stress testing would not be expected to be performed with signs and symptoms of cardiopulmonary instability and generally-recognized contraindications (e.g., unstable angina, LV dysfunction).


        For patients with an abnormal resting ECG because of left bundle branch block, pre-excitation syndrome, left ventricular hypertrophy (LVH) or digoxin therapy, an exercise or pharmacological imaging study should be considered because the accuracy of the exercise ECG in detecting provocable ischemia is reduced.


        Cardiovascular stress testing may be performed in conjunction with additional cardiac diagnostic tests including echocardiography and nuclear cardiac imaging. It is expected that only the most appropriate test(s) necessary will be performed and billed to Medicare. The routine and repetitive monitoring of such patients beyond the first cardiac stress test, in the absence of a documented change in condition (i.e. new symptoms or progression of existing symptoms) is not considered medically necessary.


        Exercise testing should be supervised by an appropriately trained physician. Exercise testing in selected patients can be performed safely by properly trained nurses, exercise physiologists, physician assistants, physical therapists, or medical technicians working directly under the supervision of a physician, who should be in the immediate vicinity and available for emergencies.


        Given the limitations of uptake, low photon energy and distribution, the perfusion imaging codes are not generally covered on the same date of service.


        Patients with initial abnormal test results have variable pre-test probabilities for adverse events, and the need and timing of follow up nuclear imaging studies must be justified in the medical record.


        All cardiovascular nuclear tests must be referred by a physician or a qualified non-physician.


        All cardiovascular nuclear tests must be performed under the general supervision of a physician. The Medicare Carriers Manual describes general supervision as applicable when a procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision guidelines, the training of the nonphysician personnel who actually perform the exercise procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the supervising physician.


        Neither exercise testing nor radiologic imaging is indicated in the initial months after PCI without specific symptoms (i.e., chest pain, ECG changes etc.).


        Cardiovascular stress testing (with or without imaging) and cardiac imaging studies are not indicated if the results will not affect patient management decisions. If a decision to perform cardiac catheterization or other angiography has already been made, there is often no need for cardiovascular stress testing and/or cardiac imaging testing.


        In the case of myocardial viability, the FDG positron emission tomography (PET) may be used following a SPECT that was found to be inconclusive. However, SPECT may not be used following an inconclusive FDG PET performed to evaluate myocardial viability.

ICD-10 Codes that Support Medical Necessity
    Group 1 Paragraph
 
    I01.0 Acute rheumatic pericarditis
    I01.1 Acute rheumatic endocarditis
    I01.2 Acute rheumatic myocarditis
    I01.8 Other acute rheumatic heart disease
    I01.9 Acute rheumatic heart disease, unspecified
    I02.0 Rheumatic chorea with heart involvement
    I05.0 Rheumatic mitral stenosis
    I05.1 Rheumatic mitral insufficiency
    I05.2 Rheumatic mitral stenosis with insufficiency
    I05.8 Other rheumatic mitral valve diseases
    I05.9 Rheumatic mitral valve disease, unspecified
    I06.0 Rheumatic aortic stenosis
    I06.1 Rheumatic aortic insufficiency
    I06.2 Rheumatic aortic stenosis with insufficiency
    I06.8 Other rheumatic aortic valve diseases
    I06.9 Rheumatic aortic valve disease, unspecified
    I08.0 Rheumatic disorders of both mitral and aortic valves
    I08.8 Other rheumatic multiple valve diseases
    I08.9 Rheumatic multiple valve disease, unspecified
    I11.0 Hypertensive heart disease with heart failure
    I11.9 Hypertensive heart disease without 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
    I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
    I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease
    I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease
    I20.0 Unstable angina
    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
    I24.0 Acute coronary thrombosis not resulting in myocardial infarction
    I24.1 Dressler's syndrome
    I24.8 Other forms of acute ischemic heart disease
    I24.9 Acute ischemic heart disease, unspecified
    I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
    I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris
    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
    I25.3 Aneurysm of heart
    I25.41 Coronary artery aneurysm
    I25.42 Coronary artery dissection
    I25.5 Ischemic cardiomyopathy
    I25.6 Silent myocardial ischemia
    I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris
    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
    I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable 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
    I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable 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
    I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with unstable angina pectoris
    I25.731 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) with angina pectoris with documented spasm
    I25.738 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
    I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina
    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
    I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina
    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
    I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unspecified angina pectoris
    I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable 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
    I25.810 Atherosclerosis of coronary artery bypass graft(s) without angina pectoris
    I25.811 Atherosclerosis of native coronary artery of transplanted heart without angina pectoris
    I25.812 Atherosclerosis of bypass graft of coronary artery of transplanted heart without angina pectoris
    I25.82 Chronic total occlusion of coronary artery
    I25.83 Coronary atherosclerosis due to lipid rich plaque
    I25.84 Coronary atherosclerosis due to calcified coronary lesion
    I25.89 Other forms of chronic ischemic heart disease
    I25.9 Chronic ischemic heart disease, unspecified
    I26.01 Septic pulmonary embolism with acute cor pulmonale
    I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale
    I26.09 Other pulmonary embolism with acute cor pulmonale
    I26.90 Septic pulmonary embolism without acute cor pulmonale
    I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale
    I26.99 Other pulmonary embolism without acute cor pulmonale
    I27.0 Primary pulmonary hypertension
    I27.1 Kyphoscoliotic heart disease
    I27.2 Other secondary pulmonary hypertension
    I27.81 Cor pulmonale (chronic)
    I27.82 Chronic pulmonary embolism
    I27.89 Other specified pulmonary heart diseases
    I27.9 Pulmonary heart disease, unspecified
    I34.0 Nonrheumatic mitral (valve) insufficiency
    I34.1 Nonrheumatic mitral (valve) prolapse
    I34.2 Nonrheumatic mitral (valve) stenosis
    I34.8 Other nonrheumatic mitral valve disorders
    I34.9 Nonrheumatic mitral valve disorder, unspecified
    I35.0 Nonrheumatic aortic (valve) stenosis
    I35.1 Nonrheumatic aortic (valve) insufficiency
    I35.2 Nonrheumatic aortic (valve) stenosis with insufficiency
    I35.8 Other nonrheumatic aortic valve disorders
    I35.9 Nonrheumatic aortic valve disorder, unspecified
    I46.2 Cardiac arrest due to underlying cardiac condition
    I46.8 Cardiac arrest due to other underlying condition
    I46.9 Cardiac arrest, cause unspecified
    I47.0 Re-entry ventricular arrhythmia
    I47.1 Supraventricular tachycardia
    I47.2 Ventricular tachycardia
    I47.9 Paroxysmal tachycardia, unspecified
    I48.0 Paroxysmal atrial fibrillation
    I48.1 Persistent atrial fibrillation
    I48.2 Chronic atrial fibrillation
    I48.3 Typical atrial flutter
    I48.4 Atypical atrial flutter
    I48.91 Unspecified atrial fibrillation
    I48.92 Unspecified atrial flutter
    I49.01 Ventricular fibrillation
    I49.02 Ventricular flutter
    I49.1 Atrial premature depolarization
    I49.2 Junctional premature depolarization
    I49.3 Ventricular premature depolarization
    I49.40 Unspecified premature depolarization
    I49.49 Other premature depolarization
    I49.5 Sick sinus syndrome
    I49.8 Other specified cardiac arrhythmias
    I49.9 Cardiac arrhythmia, unspecified
    I50.1 Left ventricular failure
    I50.20 Unspecified systolic (congestive) heart failure
    I50.21 Acute 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
    I50.31 Acute 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
    I50.41 Acute 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
    R00.0 Tachycardia, unspecified
    R00.1 Bradycardia, unspecified
    R00.2 Palpitations
    R00.8 Other abnormalities of heart beat
    R00.9 Unspecified abnormalities of heart beat
    R01.0 Benign and innocent cardiac murmurs
    R01.1 Cardiac murmur, unspecified
    R01.2 Other cardiac sounds

Medicare is establishing the following additional limited coverage for CPT/HCPCS code 78472:
Covered for:
V58.11
Encounter for antineoplastic chemotherapy and immunotherapy
Note: Use V58.11 to report baseline for left ventricular assessment prior to initiating cancer treatment with a known cardiotoxic agent(s).
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses That Support Medical Necessity
The following E code may be used as a secondary diagnosis when other covered ICD-9-CM diagnosis codes are used as the primary diagnosis.
E933.1
Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
Note: Use of this E code will provide further clarification of the need for the procedure, but does not affect coverage.

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Medical records must substantiate the medical necessity of the services, including a clinical diagnosis and the specific reason for the study.

All segments of the service must have a formal interpretation and report.

Requested records must be accompanied by a copy of the formal report and the reason for the referral for the test.

The referral
order must be kept on file in the patient’s medical record.


When HCPCS procedure code A9505 is submitted with CPT procedure codes 78451, 78452, 78453 or 78454, the formal report must indicate that the laboratory is equipped with at least a double-headed camera as well as the appropriate software to complete the study satisfactorily.

When CPT code 78472 and add-on code 78496 are submitted with perfusion codes 78451, 78452, 78453, 78454,78466, 78468 or 78469, the formal reports must document that simultaneous cardiac function studies using the first-pass technique were performed and the laboratories are equipped to perform such studies.

When billing for the purchase of radiopharmaceutical(s), a copy of the bill indicating the dosage administered, unit price per dose, name and total charge of the radioactive drug
must be made available to Medicare upon request.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

 In summary, the choice of stress testing modality depends on many factors such as the patient's ability to exercise, the resting ECG, the clinical indication for performing the test, the patient's body habitus, and history of prior revascularization.

    The following are considered medically necessary for either the stress echo or SPECT MPI:

    1. New, recurrent, or worsening cardiac symptoms AND any of the following:


        Physical inability to perform a maximum exercise workload


        A history of CAD based on a prior anatomic evaluation of the coronary arteries OR a history of CABG or PCI


        Syncope (i.e., no prodromal symptoms, not near syncope) in patient with high likelihood of CAD


        Evidence or high suspicion of ventricular tachycardia


        Age 50 years or greater and known diabetes mellitus


        New or previously unrecognized uninterpretable ECG


        Poorly controlled hypertension, generally, above 180 mm/Hg systolic, if the provider feels strongly that CAD needs evaluation prior to BP being controlled


        ECG is uninterpretable for ischemia due to any one of the following:


            o Complete Left Bundle Branch Block (right bundle branch does not render ECG uninterpretable for ischemia)

            o Ventricular paced rhythm

            o Pre-excitation pattern such as Wolff-Parkinson-White

            o > 0.5 mm ST segment depression (NOT nonspecific ST/T wave changes)
            o LVH with repolarization abnormalities, also called LVH with strain (NOT without repolarization abnormalities or by voltage criteria)

            o T wave inversion in the inferior and/or lateral leads (leads II, AVF, V5, or V6)

            o Patient on digitalis preparation

        Worsening or continuing symptoms in a patient who had a normal or submaximal exercise stress test and there is suspicion of a false negative result


        Patients with recent equivocal or borderline testing where ischemia remains a concern


        Patients on beta blocker, calcium channel blocker, and/or antiarrhythmic medication when the documentation supports that an adequate workload may not be attainable to enable a fully diagnostic exercise study


        History of false positive exercise stress test (e.g., one that is abnormal, but the abnormality does not appear to be due to macrovascular CAD)


        High pretest probability of CAD (assuming emergency evaluation and/or prompt coronary angiography not previously implemented)


    2. Patients without clear cardiac symptoms in the presence of an elevated cardiac troponin

    3. Routine study > 3 years after a PCI (stent) without cardiac symptoms and absent an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

    4. Routine study > 5 years after CABG without cardiac symptoms in a patient who has not had an evaluation for CAD within the past 2 years (stress echo, MPI SPECT, cardiac PET, coronary computed tomography angiography (CCTA), cardiac catheterization)

    5. Every 2 years in patients with documentation of previous “silent ischemia” (and diabetes mellitus) evident on previous MPI but not evident on previous exercise stress test

    6. To assess for CAD in a patient with unexplained or drug-induced intraventricular condition disturbances

    7. Prior anatomic imaging study (coronary angiogram or CCTA) to assess recently demonstrated coronary stenosis of uncertain functional significance in a major coronary branch can have one stress test with imaging

    8. Established CAD in a patient who had an acute coronary syndrome (ACS) (ST segment elevation MI (STEMI), Non–ST segment elevation MI (NSTEMI), unstable angina) event within the past 90 days provided that the patient has not undergone coronary angiography at the time of the acute event and is currently clinically stable

    9. Evaluating new, recurrent, or worsening left ventricular dysfunction/CHF

    10. Assessing myocardial viability in patients with significant ischemic ventricular dysfunction (suspected hibernating myocardium) and persistent symptoms or heart failure such that revascularization would be considered

    11. Pre-operative cardiac evaluation in patients undergoing non-cardiac surgery

    -Intermediate risk surgery (cardiac risk 1-5%) one or more cardiac risk factor(s) and inability to exercise adequately

    -high risk surgery (> 5% cardiac risk)

    12. Asymptomatic patients with uninterpretable ECG and no evaluation for cardiac disease in the past 3 years

    13. Planned cardiac or other solid-organ transplant if no cardiac evaluation has been performed within the past year

    14. Patients to be treated with interleukin 2 (a pro-atherogenic agent) for various malignant disorders, etc.

    15. Patients with disease conditions associated with CAD (e.g., DM, AAA, PVD, carotid artery disease, CRF) and no documented evaluation was performed within the preceding 2 years

    16. Stress echocardiography will be considered reasonable and necessary for the evaluation of valvular heart disease and detection and management of occult pulmonary hypertension.

    The following are considered medically necessary for cardiac PET:

    1. For the evaluation of coronary artery disease for perfusion of the heart via myocardial perfusion imaging, PET scans using either FDA-approved radiopharmaceutical Rubidium 82 (RB-82) or Ammonia N-13 when performed at rest or with pharmacological stress used for noninvasive imaging of the perfusion of the heart for the diagnosis and management of patients with known or suspected coronary artery disease, provided the following requirements are met:


        a. The PET scan (whether at rest alone or rest with stress) is performed in place of, but not in addition to, a single photon emission computed tomography (SPECT) in persons with conditions that may cause attenuation problems with SPECT, e.g., obesity (BMI greater than or equal to 35), large breasts, breast implants, left mastectomy, chest wall deformity, pleural or pericardial effusion;

        OR

        b. The PET scan (whether at rest alone or rest with stress) is used following a SPECT that was found to be inconclusive. In these cases, the PET scan must have been considered necessary in order to determine what medical or surgical intervention is required to treat the patient. (For purposes of this requirement, an inconclusive test is a test(s) whose results are equivocal, technically uninterpretable, or discordant with a patient's other clinical data and must be documented in the beneficiary's file.)


    For cardiac perfusion studies, patient selection criteria for PET scans involve an individual assessment of the pretest probability of CAD, based both on patient symptoms and risk factors:


        Patients at low risk for CAD may be adequately evaluated with exercise electrocardiography.

        Patients at high risk for CAD will typically not benefit from non-invasive assessment of myocardial perfusion since a negative test will not alter disease probability sufficiently to avoid invasive angiography.

        Myocardial perfusion imaging is potentially beneficial for patients at intermediate risk of CAD (approximately 25% to 75% disease prevalence).

    The risk can be estimated using the patient's age, sex, and chest pain quality. The range for intermediate risk can vary.

    The following summarizes a characterization for patient populations at intermediate risk for CAD:

    Typical Angina:

    Chest pain with all of the following characteristics:

    • Substernal chest discomfort with characteristic quality and duration, and provoked by exertion or emotional stress, and relieved by rest or nitroglycerin

    • Men ages 30-39

    • Women ages 30-60

    Atypical Angina:

    • Chest pain that lacks one of the characteristics of typical angina

    • Men ages 30-70

    • Women ages 50 years and older

    Non-anginal Chest Pain:

    • Chest pain that meets one or none of the typical angina characteristics

    • Men ages 50 years and older

    • Women ages 60 years and older

    2. For the determination of myocardial viability, using Fluorodeoxyglucose (F-18 FDG) as a radioactive tracer, when performed as a primary or initial diagnostic study prior to revascularization, or following an inconclusive SPECT. However, if a patient receives an FDG PET study with inconclusive results, a follow up SPECT test is not covered. The identification of patients with partial loss of heart muscle movement or hibernating myocardium is important in selecting candidates with compromised ventricular function to determine appropriateness for revascularization. Diagnostic tests such as FDG PET distinguish between dysfunctional but viable myocardial tissue and scar tissue in order to affect management decisions in patients with ischemic cardiomyopathy and left ventricular dysfunction.


    3. For the determination of cardiac involvement, using Fluorodeoxyglucose (F-18 FDG), to diagnose cardiac sarcoidosis in patients who are unable to undergo magnetic resonance imaging (MRI) scanning. Examples of patients who are unable to undergo MRI include, but are not limited to, patients with pacemakers, automatic implantable cardioverter defibrillators (AICDs), or other metal implants.

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