Cardiovascular Nuclear Medicine cpt - 78451 - 78496, a4641. a9500, j0152

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.

As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). 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.

Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual for further guidance.

032X, 0333, 034X, 035X, 049X, 061X

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

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Note: The ICD-9-CM diagnosis codes listed in this LCD do not apply to HCPCS codes A4641, A9500, A9502, A9505, J0152, J0395, J1245, J1250 and J2785.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494 and 78496:

Covered for:

250.70–250.73	Diabetes with peripheral circulatory disorders
394.0–394.2	Diseases of mitral valve
394.9	Other and unspecified mitral valve diseases
395.0–395.2	Diseases of aortic valve
395.9	Other and unspecified rheumatic aortic diseases
396.0–396.3	Diseases of mitral and aortic valves
396.8–396.9	Diseases of mitral and aortic valves
398.0	Rheumatic myocarditis
398.91	Rheumatic heart failure (congestive)
402.01	Malignant hypertensive heart disease with heart failure
402.11	Benign hypertensive heart disease with heart failure
404.00–404.03	Hypertensive heart and chronic kidney disease, malignant
404.10–404.13	Hypertensive heart and chronic kidney disease, benign
404.90–404.93	Hypertensive heart and chronic kidney disease, unspecified
410.00–410.02	Acute myocardial infarction of anterolateral wall
410.10–410.12	Acute myocardial infarction of other anterior wall
410.20–410.22	Acute myocardial infarction of inferolateral wall
410.30–410.32	Acute myocardial infarction of inferoposterior wall
410.40–410.42	Acute myocardial infarction of other inferior wall
410.50–410.52	Acute myocardial infarction of other lateral wall
410.60–410.62	True posterior wall infarction
410.70–410.72	Subendocardial infarction
410.80–410.82	Acute myocardial infarction of other specified sites
410.90–410.92	Acute myocardial infarction of unspecified site
411.0–411.1	Other acute and subacute forms of ischemic heart disease
411.81	Acute coronary occlusion without myocardial infarction
411.89	Other acute and subacute forms of ischemic heart disease other
412	Old myocardial infarction
413.0–413.1	Angina pectoris
413.9	Other and unspecified angina pectoris
414.00–414.06	Coronary atherosclerosis
414.10–414.11	Aneurysm and dissection of heart
414.19	Other aneurysm of heart
414.2–414.3	Other forms of chronic ischemic heart disease
414.8–414.9	Other forms of chronic ischemic heart disease
415.0	Acute cor pulmonale
416.0	Primary pulmonary hypertension
416.2	Chronic pulmonary embolism
416.9	Chronic pulmonary heart disease unspecified
424.0–424.3	Other diseases of endocardium
424.90–424.91	Endocarditis valve unspecified
424.99	Other endocarditis valve unspecified
425.0–425.5	Cardiomyopathy
425.7–425.9	Cardiomyopathy
427.0–427.1	Cardiac dysrhythmias
427.31	Atrial fibrillation
427.41–427.42	Ventricular fibrillation and flutter
427.5	Cardiac arrest
428.0–428.1	Heart failure
428.20–428.23	Systolic heart failure
428.30–428.33	Diastolic heart failure
428.40–428.43	Combined systolic and diastolic heart failure
428.9	Heart failure unspecified
429.0–429.6	Ill-defined descriptions and complications of heart disease
429.71	Certain sequelae of myocardial infarction not elsewhere classified
429.79	Certain sequelae of myocardial infarction not elsewhere classified other
429.81–429.83	Other ill-defined heart diseases
429.89	Other ill-defined heart diseases
441.2	Thoracic aneurysm without rupture
441.4	Abdominal aneurysm without rupture
442.2	Aneurysm of iliac artery
585.3–585.6	Chronic kidney disease
746.85	Coronary artery anomaly congenital
780.2	Syncope and collapse
786.05	Shortness of breath
786.50–786.51	Chest pain
786.59	Other chest pain
794.30–794.31	Nonspecific abnormal function study of cardiovascular system
794.39	Other nonspecific abnormal function study of cardiovascular system
972.9	Poisoning by other and unspecified agents primarily affecting the cardiovascular system
995.20–995.21	Other and unspecified adverse effect of unspecified drug, medicinal and biological substance
995.27	Other drug allergy
996.72	Other complications due to other cardiac device implant and graft
996.83	Complications of transplanted heart
V12.53	Personal history of sudden cardiac arrest
V42.1	Heart replaced by transplant
V42.2	Heart valve replaced by transplant
V43.3	Heart valve replaced by other means
V45.81	Postsurgical aortocoronary bypass status
V45.82	Percutaneous transluminal coronary angioplasty status
V45.88	Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility
V47.2	Other cardiorespiratory problems
V58.69	Long-term (current) use of other medications
V67.2	Follow-up examination following chemotherapy

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.

ICD-9-CM Codes That DO NOT Support Medical Necessity

N/A

Diagnoses That DO NOT Support Medical Necessity

All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.

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.