Cardiology Coding Alert

Learn how to make sure you get the reimbursement you deserve

When your cardiologist performs blood pool imaging (78481 or 78483) as well as a SPECT perfusion imaging (78465), you won't be reimbursed for both tests for any reason. This past April's National Correct Coding Initiative version 12.1 included this edit with a "0" modifier indicator.
 
But help is on its way. NCCI 12.2 (released July 1) will change the modifier indicator to "1" and allow you to bypass the edit with a modifier -- as long as you have documentation showing two different kinds of equipment.

Get In-Depth With Future Edit

Problem: Based on your cardiologist's documentation, your claim includes the following items:
 
• a SPECT study (78465, Myocardial perfusion imaging; tomographic [SPECT], multiple studies [including attenuation correction when performed], at rest and/or stress [exercise and/or pharmacologic] and redistribution and/or rest injection, with or without quantification)
 
• a perfusion gated wall motion study (+78478, Myocardial perfusion study with wall motion, qualitative or quantitative study [list separately in addition to code for primary procedure])
 
• stress test (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)
 
• any radiopharmaceuticals supplied by the physician office (e.g., A9500, Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries; also known as Cardiolite)
 
• any pharmacologic stress agents supplied by the physician office (e.g., J0152, Injection, adenosine for diagnostic use, 30 mg [not to be used to report any adenosine phosphate compounds; instead use A9270])
 
• the blood pool imaging portion of these tests (78481 or 78483).
 
In the past: Because this edit carried a status indicated of "0," payers would only reimburse you for the blood imaging portion and not the SPECT study. You could not apply a modifier to separate them, even when these procedures were unique from each other.
 
Future solution: As of the July 1 NCCI release, this edit will have a modifier indicator of "1." With the same list of codes, you will be able to attach modifier 59 (Distinct procedural service) to both the blood pool imaging (78481 or 78483) and the SPECT perfusion code (78465).
 
Reasoning: Modifier 59 indicates to your payer that your cardiologist performed the first-pass study (78481 or 78483) on a piece of imaging equipment that is distinct from the imaging equipment the cardiologist used for the SPECT perfusion imaging study (78465).
 
As directed by the Correct Coding Initiative contactor, "A provider may bill both codes of either code pair edit with an NCCI-associated modifier if the provider utilizes distinct, separate and different 'cameras' to perform the two procedures," says Jim Collins, ACS-CA, CHCC, CPC, CEO of the Cardiology Coalition in Matthews, N.C. Best bet: Make sure your cardiologist's documentation specifically demonstrates that the SPECT procedure consists of a SPECT perfusion imaging camera while the first-pass imaging procedure consists of a high-count-rate camera.
 
More good news: This change is retroactive to the implementation date of the edit.