Cardiology Coding Alert

Hint: One code will depend on the setting

Prepare for complicated nuclear medicine claims by challenging yourself with this example. Read the report and then decide what codes you would submit before you go any further. Then, check your answers against our experts'.

First, Read This Report

Clinical indication: Chest pain

Test: Rest/direct pharmacologic vasodilation

Radiopharmaceutical and dose: Tc-99m labeled sestamibi; 10 mCi at rest and 40 mCi following adenosine infusion

Technique: Single-day protocol; acquired a study at rest first; two hours later, the patient received a standardized five-minute adenosine infusion. The patient also received the radiopharmaceutical two minutes within the infusion.

Acquisition: Thirty minutes following the administration of radiopharmaceutical; SPECT perfusion images, gated wall images at rest and following adenosine infusion. Computer-generated left ventricular ejection fraction calculation. The provider reviewed the report generated after both the attenuation and nonattenuated corrected images.

RESULTS

SPECT perfusion: There is a small-to-moderate-size severe reduction of photon intensity within the basal inferior septal wall. The images acquired at rest show partial, though significant, improvement of photon intensity at this location.

Gated images: Left ventricle cavity size is moderately dilated. There is moderate-to-severe septal and inferior septal wall hypokinesis with mild hypokinesis elsewhere within left ventricle.

LVEF: The left ventricular ejection fraction is calculated to be approximately 30 percent.

Impression: Dilated cardiomyopathy with reduced left ventricle ejection fraction measured to be 30 percent. Small-to-moderate-size, severely decreased intensity, partially though significantly reversible basal inferior septal wall defect.

Now decide how you would code this report.

See How Your CPT Codes Compare

SPECT: First, you should report the myocardial perfusion imaging code 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 "multiple studies," says Cheryl Klarkowski, RHIT, coding specialist with Baycare Health Systems in Green Bay, Wis.

Keep in mind: This code accurately represents both one- and two-day testing protocols.

Left ventricle: You should report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) because the cardiologist evaluated the motion of the left ventricle. Code 78478 represents the actual assessment of watching the ventricle contract and relax.

Ejection fraction: The cardiologist also evaluated ejection fraction, which is the number that's generated from the wall motion study. For this service, you should report +78480 (Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]).

Key: You cannot bill 78478 unless the physician assesses the wall motion, nor can you bill 78480 unless the doctor assesses the ejection fraction, Klarkowski says. You may tend to report these codes a lot -- "My physician usually does 78478 and 78480 with the multiple studies SPECT code (78465)," she adds -- but make certain your cardiologist's documentation includes these evaluations.

Remember, if your cardiologist performs these three radiologic services in the hospital, you should append modifier 26 (Professional component) to each code (78465, 78478 and 78480).

Stress test: For the stress test portion, you should report a code from the 93015-93018 series, depending on the setting.

For example, you would 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) if your physician administers a cardiovascular stress test in the office, providing the procedure's technical component (that is, the physician's practice owns the equipment, employs the staff, pays the rent, pays the utilities, etc.) in addition to the supervision, interpretation and report.

But if your physician uses the hospital's equipment to perform a cardiac stress test and supervises the stress test and provides a written interpretation and report, you would report 93016 (... physician supervision only, without interpretation and report) for the physician supervision. To code the written interpretation and report, you shouldalso use 93018 (... interpretation and report only). Pay attention to the descriptors of these codes, which include key phrases such as "without interpretation and report" and "interpretation and report only."

In conclusion, your claim should look like this:

• 78465 (add modifier 26 if performed in the hospital)

• +78478 (add modifier 26 if performed in the hospital)

• +78480 (add modifier 26 if performed in the hospital)

• 9301x (depending on setting).

Don't Forget ICD-9 and Supply Codes

For your diagnosis code, you should report 786.50 to represent the patient's chest pain.

As for the supply codes, if your cardiologist performs these services in the office, you should report A9500 (Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries). Typically you'll report two doses of A9500 as well as the appropriate dosage of adenosine J0152 (Injection, adenosine for diagnostic use, 30 mg). (See the Reader Question "Avoid Half-Units of Adenosine" in this issue for more information.)

Note: Stacy Gregory, RCC, CPC, charge capture and reconciliation specialist for Franciscan Health Systems' Imaging Support Services in Tacoma, Wash., provided this example during her "Hot Topics in Nuclear Medicine" presentation at The Coding Institute's 2006 National Cardiology & Radiology Coding and Reimbursement Conference.
Look for information about 2007's cardiology conference at www.codingconferences.com.