Cardiology Coding Alert

When cardiologists perform multiple gated acquisition (MUGA) scans to measure various aspects of the heart's muscle function, you should report not only the scan but also any procedures performed at the same time and supplies used to ensure proper reimbursement for the physician's work.

CPT lists four codes that may apply to MUGA scans (see box on page 59). Choosing among these codes is only one part of reporting the cardiologist's services for this procedure. Because physicians occasionally perform these scans with stress tests, be sure to report all the work done by the cardiologist, as well as the supplies, says Lisa M. Clifford, CPC, owner of the multispecialty coding firm Clifford Medical Billing Specialists Inc. in Naples, Fla.

Cardiologists perform MUGA scans to measure ventricular wall motion to determine, for example, if the lower portion of the heart is damaged and, if so, to what extent. The scans can be used to evaluate patients with suspected or known coronary artery disease, valvular heart disease and after a myocardial infarction, among other conditions.

The patient's red blood cells are tagged with a radiographic tracer (usually technetium), which can be photographed with a special camera as they move through the body and synchronized with an electrocardiogram (ECG) taken at the same time. By tracing the blood's flow through the heart, the cardiac physician can determine the ventricle's ejection fraction (how much of the blood in the heart gets pumped out as a percentage of the total amount of the blood filling the heart). The higher the percentage, the better the heart is working.

Coding for the MUGA scan will depend on whether the cardiologist performs the study with the patient at rest, with exercise or with pharmacologic stress (e.g., dobutamine). If the physician tests the resting patient once, you should report 78472. Although the CPT definition indicates that the single test may be performed on patients either at rest or stressed, in most cases the cardiologist performs the single procedure on resting patients.

The cardiologist can obtain useful data when the scan is performed at rest and after exercise. If the patient cannot perform an adequate level of exertion, he or she may undergo pharmacologic stress, which is brought on by using drugs such as dobutamine.

When the cardiologist monitors the patient both at rest and at various levels of exercise, you should report 78473. According to the medical review policy of HGSAdministrators, the Medicare Part B carrier for Pennsylvania, "When cardiac blood pool imaging studies are performed during exercise and/or pharmacologic stress, the appropriate stress testing code from the 93015-93018 series should be paid in addition to the code(s) 78472 [and] 78473." The codes for the stress testing are 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), 93016 ( physician supervision only, without interpretation and report) and 93018 ( interpretation and report only).

For example, says Marko Yakovlevitch, MD, FACP, FACC, a cardiologist in private practice in Seattle, a cardiologist performs a MUGA scan on a 65-year-old patient with congestive heart failure while the patient is at rest. The physician then injects the patient with dobutamine to induce stress because the individual cannot exercise to a sufficient level of exertion. The cardiologist then performs another MUGA scan.

You should report this procedure using 78473 and 93015 if the cardiologist performs this scan in the office. If he or she does the procedure in another facility, you should report 93018 for the stress test and append modifier -26 (Professional component) to 78473. You should link the codes to the congestive heart failure diagnosis (428.0, Congestive heart failure; or 428.1, Left heart failure). Bill for the dobutamine with J1250 (Injection, dobutamine HCI, per 250 mg) if the procedure is performed in the office. If the cardiac physician performs the procedure in a hospital or other facility, it will report the medication supply.

If you perform two consecutive cardiovascular stress tests on the same day in conjunction with exercise and resting nuclear studies (including MUGA scans), however, only one of the stress studies will be reimbursed, according to HGSAdministrators' policy.

If the cardiologist induces stress for the multiple MUGA study using drugs, Medicare will pay for the pharmacologic separately from the test. You should report using dobutamine with J1250. The physician's documentation, however, must show the medical necessity to justify using the pharmacologic stress agents.

Medicare will also pay separately for providing the radioisotope for the MUGA scan. Cardiologists often use Ultratag, a technecium TC 99m-based agent, as the radiographic tracer for the scan, Yakovlevitch says. You should report the Ultratag with A4641 (Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified). Because this is an unclassified-drug code, you should include the product description, National Drug Code and the invoice with the claim when billing for its use.

If your carrier does not accept J codes, you may report 78990 (Provision of diagnostic radiopharmaceutical[s]). Although Medicare generally does not reimburse for this code, some private payers may. Carriers have the final say regarding which supplies they will reimburse, so you should check with your local carrier to determine if it will pay for your supplies.