Cardiology Coding Alert

Question: If documentation doesn’t specify wall motion or ejection fraction, do I have to use modifier 52 on 78452?

Rhode Island Subscriber

Answer: No, you should not append modifier 52 (Reduced services) to 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) when there is a lack of documentation regarding wall motion or ejection fraction.

The code descriptor states that 78452 includes “attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed.” The “when performed” wording means that those services are not required for you to report the code, but when they do occur, 78452 covers them and you should not report them separately.

Note: If the services aren’t being documented even when they are performed, be sure to include information about documenting the complete service in your next clinical documentation improvement meeting.