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Cardiology Coding Alert

Tackle This 2-Day Nuclear Study Coding Challenge

Published on Fri Sep 07, 2007

Learn which date of service CMS says you should use

If you're wondering how many doses of Cardiolite you should report for both a rest and stress nuclear medicine test, we've got answers. Read through these radiopharmaceutical coding guidelines, and then test yourself with the following two-day challenge.

Bulk Up on Radiopharmaceutical Basics

In 2006, HCPCS revised the A codes for Cardiolite, Myoview and Thallium. What's important to note is the codes for Cardiolite and Myoview 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

    •

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

    You'll use these HCPCS codes depending on the type of radiopharmaceutical and the dosage amount.

    Example: The physician uses two doses 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).

    The physician uses the first dose to perform myocardial perfusion imaging at rest. The cardiologist then uses the second for imaging at maximum exercise. Each dose of Myoview is less than 40 millicuries. If your physician provides the Myoview (that is, he performs the test in your office), report two units of A9502.

    Examine This Scenario

    Some practices use a two-day imaging protocol. In these cases, the physician obtains one set of images (rest or stress) on day one and the other set on day two. Two-day protocols throw something of a curve ball into the mix.

    First, look at this actual procedure: On the first day, the cardiologist performed the rest portion of a myocardial perfusion test, wall motion evaluation and ejection fraction calculation. He used 27 millicuries of Cardiolite. On the second day, the physician performed a stress test and used another 27 millicuries of Cardiolite. For this service, you'll report the following codes for the rest portion:

  • 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).

    • For the stress portion, you'll add the following codes to the others:

  • 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

    •

  • A9500 (1 unit).

    • Demystify the Number of Units You Should Report

    Most carriers recommend that as long as the radiopharmaceutical doses (A9500) are less than 40 mCi on each day (which would total more than one unit for the two-day test), you should report and receive reimbursement for two doses.

    But "I have received information that for Texas Medicare claims, when billing A9500, you should base your units on the quantity used, in total, during the two phases of the study (at rest and at exercise)," says Lori Chandler, CPC, cardiology coder and office manager at Clinics of North Texas in Wichita Falls.

    Get specific: According to TrailBlazer 's May 1, 2007, notice "From the Desk of the Medical Director," you should add the quantities of the two dosages. This notice states, "For dates of service on or after Jan. 1, 2006, A9500 and A9502 should be billed based on the amount of product used, in total, during the two phases of the study (at rest and during exercise).

    In other words, if the physician administers 8 mCi during the study's rest portion and 25 mCi during the exercise phase, you should tally these dosages to be 33 mCi -- and report only one unit of A9500 or A9502, as your documentation dictates. For more information, check out TrailBlazer's Web site at www.trailblazerhealth.com/Tools/Notices.aspx?ID=11863.

    Another way: Other carriers might require different means of reporting radiopharmaceuticals. For instance, "Pennsylvania Medicare requires the total cost of the Cardiolite or technetium in the narrative field, such as acquisition cost = $183.70, but in the field they only want to see one unit," says Rhonda Stewart, coder at The Heart Center at the Waterford PC in Homestead, Pa.

    Now you have your entire package of codes (78465, 78478, 78480, 93015 and A9500 x 2), but what date of service should you use -- the day the cardiologist began the test or the day he completed it?

    Confront the 2-Day Problem

    In a nutshell: 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 or the second day using the full code listing (SPECT, wall motion and ejection fraction), plus any medications supplied by your practice.-

    Keep in mind:     The Society for Nuclear Medicine wrote to the Health Care Financing Administration (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.

    Bottom line: When your physician performs a test that he ordinarily could complete in one day but spreads it over two, you should code this service the same way.

    Caution: Although this logic may recommend that you choose the second day as your date of service, a few carriers may still want you to report the codes on the first day as the actual date of service. Ask your carriers which day they prefer.

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