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.)

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.

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]). If the cardiologist measures the ejection fraction, you should bill +78480 (Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]), says Melody Mulaik, MSHS, CPC, RCC, a coding specialist with Coding Strategies Inc., an Atlanta-based coding consulting firm.

Both 78478 and 78480 are add-on codes and should be used only when you are also reporting myocardial perfusion imaging codes 78460, 78461, 78464 and 78465. They should not be billed alone.

If a patient cannot perform an adequate level of exercise for the SPECT scan, he or she may undergo pharmacologic stress. This is usually brought on by injecting the patient with drugs such as adenosine, which increases blood flow in the coronary arteries without stressing the heart muscle, Yakovlevitch notes.

When the cardiologist monitors the patient both at rest and at various levels of exercise for the SPECT scan, you should report 78465 and a cardiovascular stress test code (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; 93016, physician supervision only, without interpretation and report; or 93018, interpretation and report only).

For example, a cardiologist decides to perform a SPECT scan on a 65-year-old patient shortly after he has a heart attack to determine the amount of damage to the heart muscle. The cardiac physician performs a SPECT scan while the patient is at rest. The physician then injects the patient with adenosine to increase blood flow to the coronary arteries and performs the stress scan.

You should use 93015 (global service) with nuclear codes if the cardiologist performs the study in the office or free-standing clinic and you are billing for global services, Mulaik says. If the stress test is performed in a hospital inpatient or outpatient setting, only the professional portion(s) of the stress test may be billed. "If the cardiologist personally monitors the pharmacological stressing of the patient and renders a report (either separately or in the body of the nuclear medicine report) in the hospital setting, bill both 93016 and 93018," Mulaik recommends. You should append modifier -26 (Professional component) to the nuclear procedure code 78465.

A 12-lead electrocardiogram (ECG) and/or rhythm strip performed with the stress test is not separately reimbursed. When 93015 (global) or 93017 (professional component) is used for pharmacologic stress, there is no separate allowance for intravenous access or infusion. Medical record documentation for initial stress tests should include a complete evaluation (history and physical) of the symptoms and an ECG. When you repeat stress tests, the medical record documentation must identify separate clinical indications, Mulaik adds. You should link the codes to the heart attack diagnosis (410.xx). Bill for the adenosine with J0151 (Injection, adenosine, 90 mg) if the procedure is performed in the office. If the cardiac physician performs the procedure in a hospital or other facility, it will report the medication supply.

Although carriers will not pay for the injection of radiopharmaceuticals when performed with SPECT scans, most will reimburse for the radiopharmaceutical supply. This means the procedure report should clearly note which material and the amount used (i.e., tetrofosmin 26.2 mci, thallous chloride 4.2 mci), says Martha Gerant, CPC, a practice coder with Cardiology Services, an 11-physician practice in Shawnee Mission, Kan.

The appropriate codes for the radiopharmaceutical materials include: