Cardiology Coding Alert

When the chart reads, thallium stress test, how do you code? Very carefully, experts warn. That one extra word, thallium, written in front of a typical cardiology procedure means coding for it is anything but typical, warns Susan Callaway Stradley, CPC, CCS-P, senior consultant for Medical Group of Elliott Davis and Co., LLP, an accounting and consulting firm in Augusta, GA, .

Thallium, she notes, is one of the radioactive diagnostic imaging agents used in myocardial perfusion imaging (MPI) studies that evaluate how well blood is flowing to the myocardium. Its use should signal coders to venture outside the usual stress test range of codes (93015-93018) and into cardiovascular codes in the nuclear medicine section (78414-78499) of the CPT in order to optimize reimbursement, she says.

For example, a claim for a thallium stress test could contain as many as four CPT codes, including the following:

a stress test code - 93015-93018
a myocardial perfusion imaging code (MPI) - 78460-78465
a HCPCS code for the radiopharmaceutical
a HCPCS code for the pharmacological

Overlooking any one of these could mean youve missed reimbursement to which your practice may be ethically entitled. For example, MPI procedures do not include stress testing. So, failure to bill for it can be a loss of anywhere from $31 to $157 (depending upon whether you bill the global MPI code or just the professional component).

On the other hand, you can be in danger of upcoding, especially if you bill for an MPI reinjection when the second injection is considered part of the basic procedure. For example, a coder from Indiana asks, Our doctors do 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) on one day and then 24 hours later the patients come back for 78464 (tomographic [SPECT] single study at rest or stress [exercise and/or pharmacologic], with or without quantification). How can I correctly code for the reinjections?

The reinjection is not separately billable because the repeat imaging is inherent in the definition of 78465, explains Kenneth A. McKusick, MD, FACR, FACNP, coding and reimbursement chair for the Society of Nuclear Medicine.

So if you bill for 78465, the reimbursement would be about $697. Then if you billed for 78464 you would receive an additional $431 to which you are not ethically entitled. When the physician is performing a 78465, you cannot bill for the second injection as 78464 or you are being overpaid, Stradley cautions.

The same misconception occurs between 78460 (myocardial perfusion imaging; [planar single study, at rest or stress [exercise and/or pharmacological], with or without quantification) and 78461 (multiple studies [planar] at rest and/or stress [exercise and/or pharmacologic], and redistribution and/or rest injection, with or without quantification). Like 78465, code 78461 contains a delayed image. So when a patient, who has undergone the initial portion of 78461, returns for a subsequent reinjection that is included in 78461, 78460 should not be coded for the additional service.

Correct Billing Date

Another question often asked is: What is the correct date to list for a thallium stress test that is started on one day and completed on a subsequent day? Do you list the date the radiopharmaceutical was administered or the day the study was completed?

Because conflicting policies existed among several Medicare carriers, the Society for Nuclear Medicine wrote to HCFA and received this reply in February 1999:

The Medicare Carriers Manual, Part B, Section 2005, specifies that expenses for items and services other than expenses for surgery and childbirth are considered to have been incurred on the date the beneficiary received the item or service. When we apply this manual provision to the circumstances described in your letter relating to services that cannot be completed in a single day, a test that is reported using only one code and is conducted over more than one day would be billed showing the date the test was completed.

Four Coding Steps for Thallium Stress Tests

If you follow these steps, youll not only be safe from upcoding but youll make sure youre ethically billing for optimum reimbursement:

Step #1. Select the appropriate MPI code from the imaging range (78460-78465).

First, youll need to understand the basics of how an MPI procedure works and then compare what was actually done to the description of each procedure. (See article on page 44. Increase Nuclear Medicine Coding Reimbursement by Understanding Imaging Definitions.)

Remember, if you select 78461 or 78465, the National Correct Coding Initiative says these imaging studies are reimbursed as one test whether both portions are done on the same day or spread over two separate days. It may seem as if you should be paid for reinjections, because the patient must return, but it isnt allowed, Stradley explains.

Also, you cant bill for an introduction of the needle or intracatheter (36000), venipuncture, (36410), and intravenous injection (90784) with any of the four MPI codes, because these services are included in the MPI charge.

After selecting the appropriate MPI code, determine whether or not to bill the global code or just the professional component. The determining factor is whether or not the cardiologist owns the equipment. If he or she does not, you should append modifier -26 (professional services) to the primary code. For example, as the global code, 78461 pays approximately $320, but 78465 appended with a modifier -26 only pays $193, which is reduced because you dont own the equipment . Thus, failure to use that modifier would be overbilling of $127.

Step #2. Select the appropriate HCPCS code for the radiopharmaceutical, if appropriate.

Whether the hospital or the cardiologist bills for the radiopharmaceutical depends on which one is actually paying for it, says McKusick.

McKusick clarified this in the same letter to HCFA, whose representative wrote back the following response:

According to the Medicare Carriers Manual, Part B, Section 15030, a separate payment for radiopharma-ceuticals can be made when this supply is billed in connection with certain procedures [diagnostic radiologic procedures [including diagnostic nuclear medicine] requiring pharmaceutical or radiopharmaceutical contrast medical and/or pharmacological stressing agent).

Therefore, a separate payment for a radiopharmaceutical can be made only when the supply is billed in connection with one of the above procedures. In order to pay for a radiopharmaceutical, Medicare contractors must associate a procedure code with the contrast agent code. Both the procedure and supply can have different dates of service, since a radiopharmaceutical may have been administered several days ahead of the test. If both services are billed on the same claim, Medicare contractors can more easily associate these two services to each other even though the services may have been done several days apart. If these services are billed on separate claims with different dates of service, some Medicare contractors may not be able to associate the two services in their payment system.

For Medicare patients, use this HCPCS code to indicate the use of the thallium: A9505 (supply of radio-
pharmaceutical diagnostic imaging agent, thallous chloride TI-201, per mCi); while private insurers may require 78990 (provision of diagnostic radiopharmaceutical). This radiopharmaceutical code is for each mCi. So use it as many times as necessary to account for the entire dose, explains McKusick. For example, if three mCis were used, bill the code three times. (Check with your local carrier for their specific requirements.)

Note: You may see an imaging stress test called treadmill-MIBI that uses another radiopharmaceutical, called sestamibi, instead of thallium. It is coded the same way as a thallium stress test, except the HCPCS code is A9500 (supply of radiopharmaceutical diagnostic imaging agent, technetium Tc-99m sestamibi, per dose). This HCPCS code is per dose; therefore use it only once per injection, no matter how many MCIs of Tc99m are used, explains McKusick. But if there are two injections, for rest and stress, then use the code twice.

Step #3: Select the appropriate stress test code from the 93015-93018 range.

Check to see if the study was performed with or without exercise and determine whether the cardiologist owns the equipment.

For studies performed with exercise on your equipment, use 93015 the global code for stress testing. This means that 93015 is reported when the cardiologist provides the complete service involved in a stress test, including monitoring the patient, supervising and interrupting the result, says Stradley.

But if the cardiologist performed an exercise study in the acute care facility or outpatient portion of the hospital, only the code representing the professional portion of the stress test may be billed. Code 93016 represents the physician supervision only, without interpretation and report, and 93018 represents the interpretation and report only. The cardiologist should use 93018, for example, if a nuclear medicine physician supervised the test, even though the cardiologist will interpret the results.

Step #4: Code for the pharmacological agent, if appropriate.

Sometimes, because of an illness, injury or chronic condition, patients cannot exercise and myocardial stress is induced through an intravenous injection of pharmacological agents such as dipyridamole (Persantine), adenosine (Adenocard), or dobutamine (Dobutrex). How do you code for a dobutamine thallium stress test? asks Heidi Omoto, biller for a cardiology practice in Honolulu, HI.

Use the same rules as outlined above to select from codes 93015, 93016 and 93018. Again, if the non-exercise stress test is performed at a site where the physician does not own the equipment, then the drug is considered a hospital supply and as such cannot be billed separately by the cardiologist. But you may be entitled to bill for the drugif your practice owns the equipment. For Medicare and other payers that accept HCPCS codes, use the following:

J1245 - injection, dipyridamole, per 10 mg
J1250 - injection, dobutamine HCI, per 250 mg
J0151 - injection, adenosine (AdenoScan), 90 mg

Check with private insurers that dont accept HCPCS codes to see which code they require. They may suggest 99070 (supplies and material provided by the physician over and above those usually included with the office visit or other services rendered).

Note that many payers have strict requirements when billing for the pharmacologic agent in stress testing. Some require a copy of the pharmaceutical invoice to support the claim, notes the American College of Cardiology. Other payers cover pharmacologic stress testing only when exercise testing is documented as not possible, notes the American College of Radiology. Such payers may require that the need for pharmacologic testing be documented in the patients medical record as well as on the claim form with the appropriate ICD-9 code. And be sure to check with your payers to find out their specific requirements. Otherwise, not only the drug but the entire myocardial perfusion imaging (78460-78465) could be denied because the carrier would deem it not medically necessary.

Note: Do not bill for actual intravenous administration of the drug because that is considered part of the test and therefore, should not be coded separately.