Cardiology Coding Alert

If you don't pay attention to "per study dose" designations, you could be setting your practice up for denials.

If you miss coding the correct radiopharmaceutical (RP) used for your stress tests, you could be losing money. With special rules regarding units and multiple name-brand drugs, it's easy to see why RP claims are a common spot for errors. You can be sure your practice reports clean radiopharmaceutical and nuclear medicine claims and gets the payment it deserves by reviewing these expert answers to your most frequently asked questions.

Q: Which HCPCS Codes Apply to RPs?

A radiopharmaceutical is a radioactive agent often used in imaging for nuclear stress tests to help the cardiologist see how well blood is flowing to and through the heart. The HCPCS manual lists A9500-A9700 under the heading "Supplies for Radiology Procedures (Radiopharmaceuticals)."

Codes for RPs commonly used for stress tests include the following:

• A9500 -- Technetium Tc-99m sestamibi, diagnostic, per study dose
• A9502 -- Technetium Tc-99m tetrofosmin, diagnostic, per study dose
• A9505 -- Thallium Tl-201 thallous chloride, diagnostic, per millicurie.

Problem: The brand names associated with RPs can make your job confusing if you aren't sure which code to match to which brand name.

Solution: If your cardiologist documents that he injected Cardiolite, report A9500; for Myoview use A9502.

Q: What Does 'Per Study Dose' Refer To?

The code descriptors for some RPs specify "per study dose." So, for example, if your cardiologist uses any amount of Myoview for a single study, you would report one unit of A9502, which specifies "per study dose."

Pitfall: But actual tests aren't always so easy to code. Stress tests may include both a rest phase and a stress phase, and the provider will administer RPs for both phases. Some payers consider the rest plus stress phases to be a single study, and other payers allow you to bill for two study doses, one for each phase. You will have to check with your payers to see what they consider to be a study dose.

For example, for her payers, Donna Davis, CMC, billing manager for Cardiac Care Associates, PC in Fairfax, Va., says she reports one unit of the RP to cover both the stress and rest phases.

Pointer: The Cardiolite/sestamibi shortage is causing some practices to perform the stress phase with one isotope and the rest phase with another, Davis says. As an example, if your practice uses sestamibi for one phase and thallium for the other, you may be able to report one unit of the "per study dose" sestamibi (A9500) and however many units of the "per millicurie" thallium (A9505) your cardiologist's documentation supports. This coding works since the thallium dosage is dictated by patient weight, and a standard dose is not always used.

Be prepared: Payers may request invoices and other documentation explaining your coding. "We have had to send invoices to a few commercial payers," Davis says, "but they have reimbursed us."

Q: What Might a Sample Stress Test Claim Look Like?

When your cardiologist performs a nuclear stress test for a patient, you need to report codes for more than just the RP.

Consider the following example: Suppose your practice performs a global stress test with both rest and stress phases and SPECT myocardial perfusion imaging for both phases. The providers  dminister 0.4 mg of Lexiscan as the stress agent and a total of 41 mCi of Myoview as the RP. Summit Cardiology Business Office in Seattle calls this a "Lexiscan Nuc," says Janet Gordon-Thatcher, senior bookkeeper of patient accounts for the practice.

Solution: For the global stress test, report 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), says Gordon-Thatcher. You'll also report 78452 (Myocardial perfusion imaging, tomographic [SPECT] [including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed]; multiple studies, at rest and/or stress [exercise or pharmacologic]and/or redistribution and/ or rest reinjection) for the imaging your physician performs with the stress test, she adds.

Don't miss: For the Lexiscan, report 4 units of J2785 (Injection, regadenoson, 0.1 mg), says Gordon-Thatcher. If the payer you're reporting to requests that you submit a single unit to cover both the rest and stress phases for codes that specify "per study dose," then report one unit of A9502. Or if your payer allows you to report one unit for the rest phase dose and one unit for the stress phase dose, then report two units ofA9502, she says.