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Cardiology Coding Alert

Differentiate SPECT, MUGA, and First Pass Codes for a Formidable Bottom Line

Published on Sat Apr 23, 2005

Plus: A simple trick for identifying and coding first pass studies

If you're having a tough time figuring out what code to use for myocardial perfusion imaging studies, multi-gated acquisition scans (MUGA), and first past techniques, you're not alone. Learn the following in's and out's of these often frustratingly similar codes and take note of the National Correct Coding Initiative's most recent edit to streamline your claims every time.

Master Myocardial Perfusion Studies

Myocardial studies are usually single-photon emission computed tomography (SPECT) studies (such as 78465, Myocardial perfusion imaging; tomographic [SPECT], multiple studies [including attenuation correction when performed], at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification).

A SPECT study involves a technician injecting a radiopharmaceutical imaging agent into the patient's vein. The agent used (typically Myoview, Thallium or Cardiolite) becomes trapped in the muscle of the heart. The radiopharmaceutical then emits radiation out through the patient's chest. Finally, a special camera visualizes these emissions to provide the doctor with an image of how blood is flowing to the patient's heart muscle.

A SPECT study checks to see how the coronary arteries are supplying blood to the left ventricular myocardium - the left ventricular muscle, says Bart Outzen, RT, RT(N), CNMT, director of nuclear medicine at Cardiovascular Physicians PA in Greenville, Miss., "so you're looking for ischemia."

Equate MUGA with ERNA

In contrast to a SPECT study, "for a MUGA scan the cardiologist is looking at the blood pool to study the function of the left ventricle and not looking for ischemia," Outzen says.
 
With MUGA studies (such as 78494, Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing), some of the patient's blood is first withdrawn by venipuncture and then infused with a special radiopharmaceutical imaging agent.

During MUGA studies (such as A9512, Supply of radiopharmaceutical diagnostic imaging agent, technetium Tc 99m pertechnetate, per mci), physicians use agents that are different from those used for myocardial perfusion imaging in that they do not become absorbed by the patient's heart muscle. These agents stay in the patient's blood stream.

The radiopharmaceutical-infused blood cells circulate through the patient's vascular system several times. After several trips through the circulatory system, the agent reaches a state of "equilibrium" with the patient's blood. At this point, the technician performs the imaging. Because the radiopharmaceutical commingles with the patient's natural blood for so long, it is heavily diluted. This dilution requires the capture and averaging of data from several images over several cardiac cycles.

Keep in mind: The technical term for MUGA studies is actually ERNA or equilibrium radionuclide angiocardiography, Outzen says. Cardiologists use ERNA to determine the following information:
 

  • left ventricular volume
     
  • left ventricular ejection fraction
     
  • right ventricular ejection fraction
     
  • regional wall motion
     
  • left ventricular emptying
     
  • left ventricular filling

    Generally, these tests last about 30 minutes. Technicians will do four positions: left lateral, left anterior oblique, anterior view, right anterior oblique.

    Identify a First Pass at First Glance

    For first pass studies, (for example, 78483, Cardiac blood pool imaging [planar], first pass technique; multiple studies, at rest and with stress [exercise and/or pharmacologic], wall motion study plus ejection fraction, with or without quantification) a technician injects a radiopharmaceutical into a patient's vein while the patient is in front of a specialized camera. The camera visualizes the bolus of radiopharmaceutical as it passes from the patient's venous system through the heart and lungs. The technician performs this imaging as the agent makes its "first pass" through the heart.

    When a technician does the initial injection for a first pass study, the patient is already positioned in front of the camera (usually in left anterior oblique projection). The technician watches the nuclear tracer flow through the right and left portions of the heart. The injection time and image acquisition time are simultaneous. This is recorded with images taken half second per frame for 64 frames. "In other words, this is one very, very quick procedure with one set of pictures," Outzen says.

    First pass technique is different from a MUGA scan because for a MUGA scan, you inject the patient but don't watch the nuclear tracer flow through the patient; you simply wait five minutes and then you start taking pictures, Outzen says. If you're only performing a first pass, it'll take about 10 minutes total for the setup and imaging.

    EF note: Generally, you'll report ejection fraction (+78480, Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]) and wall motion (+78478, Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) with a SPECT study but not with a MUGA or first pass study.

    On MUGA and first pass studies, you're primarily looking at the wall motion and the ejection fraction, so you wouldn't report these add-on codes in addition to the appropriate procedure codes.

    Check Out New NCCI Edit for 78472

    When reporting "gated" studies, choose 78472 (Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress [exercise and/or pharmacologic], wall motion study plus ejection fraction, with or without additional quantitative processing) because a nuclear medicine camera takes images, which are timed to the cardiac cycle by ECG. This synchronization produces a display of cardiac wall motion.

    Important: NCCI 11.1 has put a halt to reporting 78472 in addition to 78465. As of April 1, these two codes are mutually exclusive procedures and carry a modifier indicator status of "0," meaning you cannot use modifiers to separate them.

    "This doesn't come as too much of a surprise, because it looks like many local coverage determinations (LCD) already say they generally won't cover cardiac blood pool codes and perfusion imaging codes on the same date of service," says Cynthia A. Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

    The reason is due to "limitations of uptake, low-photon energy and redistribution," according to National Heritage Insurance Company's Northern California LCD.

    And don't forget about a long-standing NCCI edit that bundles 78473 (Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress [exercise and/or pharmacologic], with or without additional quantification) into 78465. This edit also has an indicator of "0," which means no NCCI-related modifier will bypass the edit.
     
    Note: Learn how to differentiate cardiac blood pool imaging codes in next month's issue.

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