Cardiology Coding Alert

Perhaps the most common nuclear diagnostic test used by cardiologists, single-photon emission computerized tomography (SPECT) scans present several coding issues, including reporting the scan along with stress tests and radiopharmaceutical supplies. A SPECT scan often referred to as a "thallium stress test" even though cardiologists frequently use radionuclides other than thallium involves injecting the patient with a radiopharmaceutical and using a gamma camera that rotates around the body to acquire multiple projections and to generate a three-dimensional image of the heart. Physicians perform the scan to evaluate how well blood is flowing to the heart muscle, or myocardium. (For more about how SPECT scans work, see "What Are SPECT Scans?" in article 2.) SPECT Coding Basics Typically, SPECT scans are 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), which should be billed only once for both scans. According to the American College of Cardiology's Guide to CPT 2002, "Studies performed with thallium-201 have initial and delayed imaging When one of the technetium agents is used, and sometimes with thallium, two doses of radiopharmaceutical are administered one with stress and one at rest. Nevertheless, the same code [78465] is used."

Consequently, Medicare carriers reimburse the rest and stress scans as one test regardless of whether they are performed on the same or different 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 the cardiologist performs the two components of the exam over two days. Code 78464 may be appropriate, however, in certain situations. For example, a patient with coronary artery disease has a completely closed left anterior descending artery (LAD) and a partially blocked right coronary artery (RCA), says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle. 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. The patient may require only one redistribution scan to evaluate the viability of the heart muscle, Yakovlevitch says. Gated Imaging Presents More Codes In addition to the basic SPECT scan, cardiologists may use a series of gated images images taken over time using a gamma camera and integrating simultaneous electrocardiographic information to show the beating heart with the scan to assess wall motion and measure ejection fraction (the amount of blood the heart pumps out to the body).

When the cardiac physician measures wall motion using a gated SPECT scan, you should report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]). [...]