Cardiology Coding Alert

Learn whether you should -- or shouldn't -- round up units

If you're having trouble picking HCPCS codes for radiopharmaceuticals, you're not alone. Here's how to tackle four common challenges and come up with the correct codes every time.

Use These Radiopharmaceutical Basics

When you're reporting radiopharmaceuticals, you'll report the specific radioisotope or stressing agent and the quantity your cardiologist injects. Choose from the following HCPCS codes:

• J0152 -- Injection, adenosine, 30 mg

• J1245 -- Injection, dipyridamole, per 10 mg (also called Persantine)

• J1250 -- Injection, dobutamine HCI, per 250 mg.

HCPCS 2006 revised the A codes for Cardiolite, Myoview and Thallium. The codes for Cardiolite and Myoview now have a specified limit:

• Cardiolite: A9500 -- Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries

• Myoview: A9502 -- Technetium Tc-99m tetrofosmin, diagnostic, per study dose, up to 40 millicuries.

The code for Thallium has a new look, but you will still report it per millicurie:

• Thallium: A9505 -- Thallium Tl-201 thallous chloride, diagnostic, per millicurie.

Example: The physician uses 40 millicuries of Myoview to perform a myocardial perfusion study that merits 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). If your physician provides the Myoview, report one unit of A9502.

Caution: You should avoid using 78990 (Provision of diagnostic pharmaceutical[s]) because CPT deleted this code last year, says Rehna Burge, radiology and cath lab billing analyst for North Oaks Medical Center in Hammond, La.

How to Code Second-Day Stress Test

Problem 1: A patient returns to your office on a second day for the stress thallium portion of a SPECT scan because the cardiologist could not complete the test the first day due to scheduling constraints. The cardiologist uses 10 millicuries of thallium.

You should code the session as follows:

• 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

• 78465

• A9505 x 10.

When your cardiologist performs the rest or stress portions of the SPECT scan on two separate days, you should report the test on either the first day or the second day using the full listing of codes (SPECT, wall motion and ejection fraction) plus any medications supplied by your practice. 

Keep in mind: The Society for Nuclear Medicine wrote to HCFA -- now CMS -- 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.

Although this logic may recommend that you choose the second day as your date of service, some carriers want you to report the codes on the first day as the actual date of service. Check with your carriers to see which day they prefer.

Make the Most of More Than 40 Millicuries

Problem 2: If your cardiologist obtained gated images using sestamibi (10 millicuries during the rest portion and 30 millicuries during the stress portion), you should report the following codes:

• 93015

• 78465

• +78478 -- Myocardial perfusion study with wall motion, qualitative or quantitative study (list separately in addition to code for primary procedure)

• +78480 -- Myocardial perfusion study with ejection fraction (list separately in addition to code for primary procedure)

• A9500 (1 unit).  

If your cardiologist uses more than 40 millicuries, then you should report the sestamibi code (A9500) once with two units, says Kelly Sexton, RMC, business office manager at Tri-State Cardiology PC in Johnson City, Tenn.

Determine Whether to Round Up

Problem 3: If your cardiologist uses 31.1 mg of Persantine vasodilatation for the study's stress portion and obtains a gated SPECT study, report the following:

• 93015

• 78465

• 78478 

• 78480

• A9500

• J1245 x 4.

Red flag: According to the Medicare Claims Processing Manual Chapter 17, titled "Drugs and Biologicals," you should bill drugs "in multiples of the dosage specified in the HCPCS/NDC. If the dosage given is not a multiple of the HCPCS code, the provider rounds to the next highest units in the HCPCS description for the code."

This means that when you're reporting Persantine (J1245) by dose, you should round up to the next unit, because you do not have a mechanism for reporting only partial units. You should report four units for 31.1 mg.

Know What to Do for Patient No-Show

Problem 4: Your patient is supposed to have a diagnostic or therapeutic procedure, but he doesn't show up for his appointment.

Bottom line: You should not bill for radiopharmaceuticals that your cardiologist does not use. Patient "no-shows" can be a big problem because many radiopharmaceuticals have a short shelf life and may need to be used within hours.

When a patient misses an appointment and your cardiologist does not use the agent, it will degrade and be rendered unusable. Unfortunately, this loss is not billable to insurance. 

"If a patient does not show up for a procedure, you cannot charge for the pharmaceutical," Burge says.
 
Tactic: Some practices have instituted a "missed appointment" fee that they bill directly to the patient. Using such fees must be approved within the contract that the practice has with payers.