Cardiology Coding Alert

Replacing standard stress tests with SPECT won’t fly.

Audits of myocardial SPECT claims are revealing some widespread problems, with medical necessity being a major issue.

Keep your practice in the clear with this advice from Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Know What’s in the SPECT NCD

Language in National Coverage Determination (NCD) 220.12 regarding “myocardial SPECT is very limiting with regard to coverage,” says Bucknam.

The NCD states SPECT is useful to “analyze blood flow to an organ, as in the case of myocardial viability” and to “differentiate ischemic heart disease from dilated cardiomyopathy,” Bucknam says, quoting the NCD.

“Make sure that documentation supports one of these reasons as the medical necessity for the test and that any other testing (e.g., EKG or echocardiogram) prior to the SPECT test supports that medical necessity,” Bucknam says.

Factor In This FDG PET Tip

Under the Indications and Limitations of Coverage section, the NCD states, “In the case of myocardial viability, 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,” Bucknam says.

Let’s break that down. If the patient requires testing for myocardial viability, then the sequencing of testing matters for coverage.

Covered: This is OK, according to the NCD to test for myocardial viability:

1. The patient has an inconclusive SPECT
2. The patient then has an FDG PET.

Not covered: This is not OK, according to the NCD to test for myocardial viability:

1. The patient has an inconclusive FDG PET
2. The patient then has a SPECT.

Simplify Meeting Medical Necessity Requirements

“The big reason for denials that I have seen is medical necessity. There seems to be a trend toward ordering these SPECT tests instead of standard stress tests, and Medicare will not pay for that,” Bucknam explains.

Smart move: “If cardiology or nuclear medicine practices are allowing internal medicine and other specialties to order these tests without preliminary evaluation by a cardiologist, the cardiologist/nuclear medicine physician who will do the interpretation may want to create a tip sheet or list of diagnoses to help prevent denials from their referral sources. Otherwise they could be in trouble as prepayment audits are underway, at least in some parts of the country,” Bucknam says.

To prepare your tip sheet, check your MAC’s local coverage determination (LCD) for covered diagnoses and coverage rules, and watch for any advice the MAC has posted regarding their own SPECT audits. Keep in mind that in addition to medical necessity, you’ve got to meet the usual requirements like “a signed and dated order and a full report with interpretation, signed and dated as well,” Bucknam says.

For instance: Noridian performed a widespread review of 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) in southern California.

The error rate found was 74.17 percent. In the review findings posted online, Noridian provides a link to its LCD related to 78452 and provides a documentation guide to help with ensuring the medical record has what it needs.

You can see Noridian’s review findings at https://med.noridianmedicare.com/web/jeb/cert-reviews/mr/notifications-findings/myocardial-perfusion-imaging-tomographic-spect-78452-southern-ca-widespread-service-specific-probe-review-findings.