Cardiology Coding Alert

To select the correct HCPCS code, you'll need to know both the drug type and exactly how much stressing agent a patient received, White emphasizes.

Usually, you indicate the dosage in multiples. For instance, if a patient received a total of 20 mg of Persantine which comes in 10-mg vials during the stress portion of study, you would report J1245 x 2 units, White says.

Reporting the correct code when the patient receives less than 90 mg can be tricky, depending on your local Medicare carrier's policy. Some carriers stipulate that when a patient receives less than 90 mg, you should report J3490 (Unclassified drugs), says Anne Karl, RHIA, CCS-P, CPC, a coding and compliance specialist with the St. Paul Heart Clinic in Mendota Heights, Minn.

Because J3490 is an unclassified-drug code, enter the actual dosage used, such as "Adenosine 60 mg," in box 19 of the CMS 1500 form, Karl advises. She adds that her practice has tried filing separate claims for the unlisted adenosine, but insurers don't understand why they are billing this code alone. If you use the unlisted code, be prepared for payment delays, she notes.

Some carriers prefer that you report J0151 and list the appropriate adenosine dosage on the 1500 form.

For the study's stress portion, report 93015 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report). Notice that the description includes the phrase "and/or pharmacological stress," White says. This means that you can report 93015 when the patient does not use the treadmill and has pharmacologically induced stress, she says.

Code 93015 is global and can be used with nuclear codes if the cardiologist performs the study in the office or freestanding clinic, and you are billing for global services, White says.

If the cardiologist supervises the study but does not interpret it, report 93016 ( physician supervision only, without interpretation and report). If the physician provides only the official stress test interpretation, use 93018 ( interpretation and report only), Karl says.

You would not use modifiers with 93016 and 93018 because they are broken out of global code 93015.

In most cases, patients receive two scans one at-rest scan and a stress scan. You should report 78465 (Myocardial perfusion imaging; tomographic [SPECT], multiple studies, at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification) for both rest and stress scans, White says. Code 78465 covers both resting and stress imaging, even if the scans take place on two separate days, she says. You cannot bill it twice, and you can't bill it two days in a row.

Don't forget to append modifier -26 (Professional component) if the equipment is not yours, she notes.

Insurance carriers, including Medicare, reimburse the rest and stress scans as one test, regardless of whether the scans occur on the same or different days.

Sometimes, patients cannot complete all portions of the nuclear scan, particularly those with breathing problems or who are claustrophobic and cannot tolerate enclosure in the scanner. When this occurs, you can bill 78465 and append modifier -53 (Discontinued procedure), White says. Be aware that the carrier may pay you at a lower rate. You can bill for isotope and stress agent injection, if appropriate, depending on whether the patient received these drugs prior to test termination, she says.

If the results of either a rest or a stress scan clearly show that the patient will not need more than one scan, report 78464 (... single study at rest or stress) for a single resting or stress study.

Routinely, nuclear scans include gated images, which integrate both gamma camera images and simultaneous electrocardiographic data on heart function. Gated studies include assessments of heart wall motion and measurements of the amount of blood the heart pumps (ejection fraction).

Report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) when the cardiologist measures wall motion, and + 78480 (Myocardial perfusion study with ejection fraction) when the cardiologist measures ejection fraction.

Remember that codes 78478 and 78480 are add-on codes and should be reported with myocardial perfusion imaging codes, such as 78464 and 78465.

The wall motion and ejection fraction studies should be specified in the patient's medical record.

With a typical nuclear stress test, you may have two separate sets of diagnosis codes to consider: one set for the nuclear scan codes (78465, 78478 and 78480) and another set for the stress test (93015).

You'll need to know what primary and secondary diagnoses are approved for these codes, White says.

For instance, some Medicare carriers require a primary and secondary diagnosis for code 93015. If you have two diagnoses for a patient, such as chest pain (786.50) and shortness of breath (786.05), but both are on the primary list, the claim may be denied for lack of medical necessity, White says.

You can't change the diagnosis, but sometimes further examination of a physician's report can yield additional appropriate diagnoses, such as high cholesterol (272.4), that will fit the secondary category. If you don't have diagnoses to support medical necessity, you may need to have patients sign advance beneficiary notices (ABNs).

Check the local medical review policies (LMRP) Web site, www.lmrp.net, for carrier guidelines in your state and contact private carriers for their guidelines, White says.

Editor's note: For more information on nuclear stress tests, see "Get the Most Out of Coding for SPECT Scans" in the September 2002 Cardiology Coding Alert.