Cardiology Coding Alert

If you're not reporting 78478 and 78480 for wall motion and ejection fraction studies with myocardial perfusion studies, you could be forfeiting about $160 per patient.
 
But don't expect easy pay when you do report these claims. For full reimbursement, you may have to establish that your physician performed extra work for these separately billable services, coding experts say.

Distinguish the Add-On From the Main Scan

 You should be able to determine from the nuclear imaging report that the study includes wall motion and ejection fraction. So, when the physician assesses ventricular function in addition to the myocardial perfusion study, report +78478 (Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure]) with the appropriate main codes for myocardial perfusion and single photon emission computed tomography (SPECT) studies (78460-78465).
 
Wall motion studies or "gated" studies are separate from the perfusion imaging, says Ron Bar-Haim, CNMT, with Athens Cardiology Group in Athens, Ga.
 
During gated wall motion studies, the heart's electrical impulses trigger a camera to take a series of pictures during a cardiac cycle, which the physician uses to determine how well the ventricles are functioning, Bar-Haim says. Gated wall motion calculations are standard in about 90 percent of perfusion studies, but you would not perform them on patients with abnormal heart rhythms, he says. 
 
For ejection fraction measurements with perfusion studies, you should report +78480 (Myocardial perfusion study with ejection fraction [list separately in addition to code for primary procedure]).
 
Append modifier -26 (Professional component) to both 78478 and 78480 if the physician performs the wall motion and ejection fraction studies in the hospital.

Don't Take Nuclear Add-On Billing for Granted

Billing 78478 and 78480 as separate services with myocardial perfusion studies is more important now than ever before because some payers are starting to view nuclear scan add-on services as pricey, unnecessary extras.
 
Indeed, nuclear scan add-on services are attracting Office of Inspector General (OIG) scrutiny because Medicare payment for wall motion and ejection fraction is exceeding $150 million per year, according to an OIG memo released in late 2002. 
 
Because wall motion, ejection fraction and gating require "little extra time and effort" from nuclear technicians, the OIG proposes reviewing the relative value units (RVUs) for these add-ons and "adding new base myocardial perfusion imaging (MPI) codes which are inclusive of gating and add-ons." If these changes come about, you would continue to report existing myocardial perfusion codes when the physician does not order gating and add-ons, the memo states.
 
Don't expect just Medicare payers to cut back on add-on procedure payment. Private payer Aetna US Healthcare is taking the lead in nuclear add-on bundling, and other private payers could follow suit.
 
Indeed, Aetna denies ejection fraction payment (78480) when billed with 78478 for wall motion studies and maintains that 78480 is incidental to 78478, according to Myrna Needle, a financial recovery specialist for the North Phoenix Heart Center in Phoenix. Aetna reasons that the ejection fraction measurement is computer-generated and does not require extra work, but it does not consider that the physician must interpret these measurements, she says.
 
Convince Payers That 78480 Requires Extra Work

Even if add-on nuclear services appear to be in jeopardy, that doesn't mean you should give up reporting these claims, coding experts say. On the contrary, vigilance in documenting wall motion and ejection fraction during perfusion studies could help convince wavering payers that these additional studies require extra work.
 
For ejection fraction claims (78480), make sure the perfusion report includes a percentage measurement, Bar-Haim says. For instance, the documentation could show an ejection fraction calculation at 67 percent, he says. And, you should educate payers that these ejection fraction calculations require extra computer work. The technician has to operate several automated programs to generate the numbers, he adds.
 
Also, explain that the physician had to interpret these findings, using his or her comments on ejection fraction and wall motion as your evidence. Look for such key terms in the comments as ejection fraction "within normal range" or wall motion is "normal, hypokinetic, or dyskinetic," Bar-Haim says.
 
To make an even stronger case for 78480, stress to payers that the ejection fraction calculation gives information that is distinct from wall motion data that helps the physician better diagnose a patient's condition.
 
For example, if a patient has normal perfusion but reduced ejection fraction, that could indicate cardiomyopathy (425.x), Bar-Haim says. Low ejection fractions result in higher mortality rates. If a cardiologist did not have the ejection fraction calculation and just looked at the perfusion and saw that it was normal, that could change his interpretation of the perfusion study and could lead to a serious misdiagnosis, he says. 
 
If you encounter denials for wall motion claims (78478), point out that the study helps physicians distinguish between perfusion defects and other soft-tissue artifacts, such as diaphragmatic attenuation or breast attenuation.