Cardiology Coding Alert
Dont Miss Payment Opportunities When Coding Nuclear Scans
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 artery (LAD), and a right circumflex artery (RCX) is blocked, the cardiac surgeon must know if the heart muscle is still alive beyond the block. If not, there may be no point in performing a bypass. Only one study may be required if the stress SPECT test is normal and the cardiologist sees no reason to perform a second test at rest.
Planar Scans
An older version of the thallium stress test involves two-dimensional images of the heart muscles (the SPECT scan provides a three-dimensional image). A gamma camera records whether the isotope has been delivered to the heart muscle. If the area is dark, either there is impaired blood flow to the muscle (ischemia), or the muscle is dead (myocardial infarction, or MI).
A few hours later, after the thallium has redistributed, new images are obtained. If the area is still black, the finding (defect) represents an old MI. If the area looks normal, there is probably a partial blockage in the artery.
Much as with the SPECT scan, images from these planar tests are typically obtained under stress (again, exercise or pharmacologic) and at rest. In such cases, the procedure is coded 78461 (... multiple studies, [planar] at rest and/or stress [exercise and/or pharmacologic], and redistribution and/or rest injection, with or without quantification).
If a single study (either under stress or at rest) is obtained, 78460 (... [planar] single study, at rest or stress [exercise and/or pharmacologic], with or without quantification) should be used.
Medicare carriers will cover either a planar or a SPECT study -- but not both -- when medically necessary.
Gated Imaging
A series of "gated" images is often used with SPECT scans performed with technetium-based pharmaceuticals (e.g., sestamibi). These assess coronary wall motion and measure ejection fraction by providing images of the beating heart over time, further increasing the specificity of the test, Yakovlevitch says.
The images over time are acquired using a gamma camera that integrates simultaneous electrocardiograph information with the images obtained by the camera. Key diagnostic information can be obtained about the left ventricle, including wall motion, ejection fraction, volume and function.
First pass imaging, a related technique, follows the bolus of the radiopharmaceutical as it quickly makes its way through the right heart, lungs and left heart. Blood flow, pulmonary vasculature, major cardiac vessels and the heart chambers are visualized during this short transit. Subsequent computer analysis yields similar information to gated imaging.
Both the wall motion and ejection fraction studies can be performed either with planar or SPECT single or multiple nuclear scans. Each has a separate code:
Both 78478 and 78480 are add-on codes and may be used only with 78460, 78461, 78464 and 78465. Neither should be billed alone.
Other Billing Issues
Cardiovascular stress test codes 93015-93018 may be billed in addition to any of the nuclear medicine codes (i.e., 78460, 78461, 78464 and 78465). If the procedure is performed in the hospital, the appropriate nuclear code requires that modifier -26 (professional component) be appended. Code 93018 does not require modifier -26 because supervision and interpretation is already factored into it.
The procedure notes should document that a SPECT scan was performed by specifically noting the word "SPECT," Yakovlevitch says. If wall motion and ejection fraction analysis are also performed, they should be documented clearly and prominently in the operative report.
The operative note should also include the reason the tests were performed. Typically, carriers allow many indications and/or diagnoses to support the medical necessity of myocardial perfusion imaging. The lists of indications or payable diagnoses may vary somewhat from carrier to carrier, however. When in doubt, ask your carrier for a copy of its policy on nuclear scans.
Although electrocardiographs (ECGs, 93000 or 93010) are not bundled with nuclear scans in the national Correct Coding Initiative, they are included in stress tests. Therefore, if 93015-93018 was performed, any ECGs should not be billed separately. Similarly, the injection of the radiopharmaceutical is bundled with the nuclear scan and should not be reported.
Report Supplies Separately
Most carriers pay for radiopharmaceuticals. This means the operative report should clearly note which material was used. If a pharmacologic agent was used to induce stress, that too is separately payable. The appropriate codes for these materials are found in HCPCS:
These supply codes should be used when billing Medicare carriers. Some private carriers may prefer CPT 78990 (provision of diagnostic radiopharmaceutical[s]), Fletcher says. She adds that if the patient's heart is stressed pharmacologically, private payers may be separately billed for the drug used.
For example, if the patient had a stress thallium (SPECT) test in the cardiologist's office, the session would be coded as follows:
93015
78465
A9505.
Note: It may be necessary to indicate the number of thallium units used when billing A9505.
If gated images were obtained using sestamibi, the following codes should be used:
93015
78465
78478
78480
A9500.
If stress is induced by Persantine and a gated SPECT study is obtained, report the following:
93015
78465
78478
78480
A9500
J1245 (injection, dipyridamole, per 10 mg).
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