Cardiology Coding Alert

Last issue, Cardiology Coding Alert covered coding and billing for exercise and pharmacological stress testing. Although treadmill testing alone is a reasonable standard of care for patients with a low likelihood of disease, it may not be sufficiently accurate for higher-risk patients or those with pre-existing conditions. For these patients, the cardiologist might combine treadmill tests with other diagnostic services involving imaging, such as myocardial perfusion imaging studies (single-photon emission computerized tomography [SPECT] scans, wall motion and ejection fraction analyses) or stress echocardiography.

Coding nuclear scans is not the same as coding stress echos, except that with either technique the stress portion of the test should be billed separately. In addition, regardless of which technique is performed, any pharmacologic agent used to induce stress should be billed separately.

Note: For a detailed discussion of stress echos, see Cardiology Coding Alert, October 2000, pp. 81-85.
Coding SPECT Scans
A SPECT scan -- often referred to as a "thallium stress test," even though thallium may not be the isotope used -- is the most common nuclear diagnostic test. Unlike other tests also known as thallium stress tests (reported using different CPT codes), SPECT involves a gamma camera scan (using technology similar to a CT scan) that rotates around the body, acquiring multiple projections and generating an image of the source on a computer screen. The scan is performed to evaluate how well blood is flowing to the heart muscle (myocardium).

A typical SPECT scan is coded 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).

A second set of images is usually obtained, either a few hours later or on the following day. In either case, 78465 should be billed only once for both scans, says Terry Fletcher, BS, CPC, CCS-P, a cardiology coding and reimbursement specialist in Laguna Beach, Calif. She notes that according to the American College of Cardiology's Guide to CPT, "Studies performed with thallium-201 have initial and delayed imaging .... When one of the technetium agents is used [sestamibi, for example], and sometimes with thallium, two doses ... are administered -- one with stress and one at rest. Nevertheless, the same code [78465] is used."

Accordingly, Medicare carriers reimburse rest/stress tests as one test whether they are performed on the same day or on two separate days. Two single studies (78464, ... tomographic [SPECT], single study at rest or stress [exercise and/or pharmacologic], with or without quantification) should not be billed when two tests are performed over two days.

Code 78464 is sometimes appropriate, notes Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle. For example, if a patient with coronary artery disease has a completely closed left anterior descending [...]